A Predictive Score for Bronchopleural Fistula Established Using the French Database Epithor.

PubMed

Pforr, Arnaud; Pagès, Pierre-Benoit; Baste, Jean-Marc; Thomas, Pascal; Falcoz, Pierre-Emmanuel; Lepimpec Barthes, Francoise; Dahan, Marcel; Bernard, Alain

2016-01-01

Bronchopleural fistula (BPF) remains a rare but fatal complication of thoracic surgery. The aim of this study was to develop and validate a predictive model of BPF after pulmonary resection and to identify patients at high risk for BPF. From January 2005 to December 2012, 34,000 patients underwent major pulmonary resection (lobectomy, bilobectomy, or pneumonectomy) and were entered into the French National database Epithor. The primary outcome was the occurrence of postoperative BPF at 30 days. The logistic regression model was built using a backward stepwise variable selection. Bronchopleural fistula occurred in 318 patients (0.94%); its prevalence was 0.5% for lobectomy (n = 139), 2.2% for bilobectomy (n = 39), and 3% for pneumonectomy (n = 140). The mortality rate was 25.9% for lobectomy (n = 36), 16.7% for bilobectomy (n = 6), and 20% for pneumonectomy (n = 28). In the final model, nine variables were selected: sex, body mass index, dyspnea score, number of comorbidities per patient, bilobectomy, pneumonectomy, emergency surgery, sleeve resection, and the side of the resection. In the development data set, the C-index was 0.8 (95% confidence interval: 0.78 to 0.82). This model was well calibrated because the Hosmer-Lemeshow test was not significant (χ(2) = 10.5, p = 0.23). We then calculated the logistic regression coefficient to build the predictive score for BPF. This strong model could be easily used by surgeons to identify patient at high risk for BPF. This score needs to be confirmed prospectively in an independent cohort. Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

PREOPERATIVE PREDICTION OF LUNG FUNCTION IN PNEUMONECTOMY BY SPIROMETRY AND LUNG PERFUSION SCINTIGRAPHY

PubMed Central

Cukic, Vesna

2012-01-01

Introduction: Nowadays an increasing number of lung resections are being done because of the rising prevalence of lung cancer that occurs mainly in patients with limited lung function, what is caused by common etiologic factor - smoking cigarettes. Loss of lung tissue in such patients can worsen much the postoperative pulmonary function. So it is necessary to asses the postoperative pulmonary function especially after maximal resection, i.e. pneumonectomy. Objective: To check over the accuracy of preoperative prognosis of postoperative lung function after pneumonectomy using spirometry and lung perfusion scinigraphy. Material and methods: The study was done on 17 patients operated at the Clinic for thoracic surgery, who were treated previously at the Clinic for Pulmonary Diseases “Podhrastovi” in the period from 01. 12. 2008. to 01. 06. 2011. Postoperative pulmonary function expressed as ppoFEV1 (predicted postoperative forced expiratory volume in one second) was prognosticated preoperatively using spirometry, i.e.. simple calculation according to the number of the pulmonary segments to be removed and perfusion lung scintigraphy. Results: There is no significant deviation of postoperative achieved values of FEV1 from predicted ones obtained by both methods, and there is no significant differences between predicted values (ppoFEV1) obtained by spirometry and perfusion scintigraphy. Conclusion: It is necessary to asses the postoperative pulmonary function before lung resection to avoid postoperative respiratory failure and other cardiopulmonary complications. It is absolutely necessary for pneumonectomy, i.e.. maximal pulmonary resection. It can be done with great possibility using spirometry or perfusion lung scintigraphy. PMID:23378687

Partial pneumonectomy of telomerase null mice carrying shortened telomeres initiates cell growth arrest resulting in a limited compensatory growth response

PubMed Central

Jackson, Sha-Ron; Lee, Jooeun; Reddy, Raghava; Williams, Genevieve N.; Kikuchi, Alexander; Freiberg, Yael; Warburton, David

2011-01-01

Telomerase mutations and significantly shortened chromosomal telomeres have recently been implicated in human lung pathologies. Natural telomere shortening is an inevitable consequence of aging, which is also a risk factor for development of lung disease. However, the impact of shortened telomeres and telomerase dysfunction on the ability of lung cells to respond to significant challenge is still largely unknown. We have previously shown that lungs of late generation, telomerase null B6.Cg-Terctm1Rdp mice feature alveolar simplification and chronic stress signaling at baseline, a phenocopy of aged lung. To determine the role telomerase plays when the lung is challenged, B6.Cg-Terctm1Rdp mice carrying shortened telomeres and wild-type controls were subjected to partial pneumonectomy. We found that telomerase activity was strongly induced in alveolar epithelial type 2 cells (AEC2) of the remaining lung immediately following surgery. Eighty-six percent of wild-type animals survived the procedure and exhibited a burst of early compensatory growth marked by upregulation of proliferation, stress response, and DNA repair pathways in AEC2. In B6.Cg-Terctm1Rdp mice carrying shortened telomeres, response to pneumonectomy was characterized by decreased survival, diminished compensatory lung growth, attenuated distal lung progenitor cell response, persistent DNA damage, and cell growth arrest. Overall, survival correlated strongly with telomere length. We conclude that functional telomerase and properly maintained telomeres play key roles in both long-term survival and the early phase of compensatory lung growth following partial pneumonectomy. PMID:21460122

Effect of phrenic nerve palsy on early postoperative lung function after pneumonectomy: a prospective study.

PubMed

Kocher, Gregor J; Mauss, Karl; Carboni, Giovanni L; Hoksch, Beatrix; Kuster, Roland; Ott, Sebastian R; Schmid, Ralph A

2013-12-01

The issue of phrenic nerve preservation during pneumonectomy is still an unanswered question. So far, its direct effect on immediate postoperative pulmonary lung function has never been evaluated in a prospective trial. We conducted a prospective crossover study including 10 patients undergoing pneumonectomy for lung cancer between July 2011 and July 2012. After written informed consent, all consecutive patients who agreed to take part in the study and in whom preservation of the phrenic nerve during operation was possible, were included in the study. Upon completion of lung resection, a catheter was placed in the proximal paraphrenic tissue on the pericardial surface. After an initial phase of recovery of 5 days all patients underwent ultrasonographic assessment of diaphragmatic motion followed by lung function testing with and without induced phrenic nerve palsy. The controlled, temporary paralysis of the ipsilateral hemidiaphragm was achieved by local administration of lidocaine 1% at a rate of 3 mL/h (30 mg/h) via the above-mentioned catheter. Temporary phrenic nerve palsy was accomplished in all but 1 patient with suspected catheter dislocation. Spirometry showed a significant decrease in dynamic lung volumes (forced expiratory volume in 1 second and forced vital capacity; p < 0.05) with the paralyzed hemidiaphragm. Blood oxygen saturation levels did not change significantly. Our results show that phrenic nerve palsy causes a significant impairment of dynamic lung volumes during the early postoperative period after pneumonectomy. Therefore, in these already compromised patients, intraoperative phrenic nerve injury should be avoided whenever possible. Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Bronchovascular versus bronchial sleeve resection for central lung tumors.

PubMed

Lausberg, Henning F; Graeter, Thomas P; Tscholl, Dietmar; Wendler, Olaf; Schäfers, Hans-Joachim

2005-04-01

Pneumonectomy has traditionally been the treatment of choice for central lung tumors. Bronchial sleeve resections are increasingly considered as a reasonable alternative. For tumor involvement of both central airways and pulmonary artery, bronchovascular sleeve resections are possible, but considered to be technically demanding and associated with a higher perioperative risk. In addition, their role as adequate oncologic treatment for lung cancer is unclear. We have compared the early and long-term results of bronchovascular sleeve resection with those of bronchial sleeve resection and pneumonectomy. We retrospectively analyzed all patients who underwent bronchial sleeve resection (group I, n = 104), bronchovascular sleeve resection (group II, n = 67), and pneumonectomy (group III, n = 63) for central lung cancer in our institution. The groups were comparable regarding demographics and tumor, node, and metastasis (TNM) stage. Early mortality was 1.9% in group I, 1.5% in group II, and 6.3% in group III (p = 0.19). The rate of bronchial complications was 0.96% in group I, 0% in group II, and 7.9% in group III (p = 0.006). Five-year survival was 46.1% in group I, 42.9% in group II, and 30.4% in group III (p = 0.16). Freedom from local recurrence of disease (5 years) was 83.8% in group I, 84.2% in group II, and 88.7% in group III (p = 0.56). Bronchovascular sleeve resections are as safe as bronchial sleeve resections for the treatment of central lung cancer. Both procedures have comparable early and long-term results, which are similar to those of pneumonectomy. It appears reasonable to apply bronchovascular sleeve resections more liberally.

Comparison of surgical outcomes after pneumonectomy and pulmonary function-preserving surgery for non-small cell lung cancer.

PubMed

Higuchi, Mitsunori; Takagi, Hironori; Ozaki, Yuki; Inoue, Takuya; Watanabe, Yuzuru; Yamaura, Takumi; Fukuhara, Mitsuro; Muto, Satoshi; Okabe, Naoyuki; Matsumura, Yuki; Hasegawa, Takeo; Osugi, Jun; Hoshino, Mika; Shio, Yutaka; Suzuki, Hiroyuki

2018-04-17

According to previous reports, lobectomy with bronchoplasty or angioplasty is a more feasible surgery than pneumonectomy for central-type non-small cell lung cancer. However, few studies have compared both the short- and long-term outcomes between pneumonectomy and pulmonary function-preserving surgery. From January 2004 to December 2015, 18 patients underwent pneumonectomy (Group PN) and 12 patients underwent pulmonary function-preserving surgery (group PS) at Fukushima Medical University Hospital. Clinicopathological factors were statistically compared between the two groups. The operation times in Group PN and Group PS were 285.9±27.9 and 271.3±99.2 min, respectively (p=0.613), while the amounts of intraoperative bleeding were 324.8±248.9 and 164.5±116.6 g, respectively (p=0.020). The duration of chest drainage and hospitalization after surgery in both groups were not significantly different but there was a tendency toward shorter periods of these durations in Group PS. The 5-year disease-free survival (DFS) rate in Group PN and PS was 51.4% and 74.1%, respectively, without a significant difference (p=0.298). The 5-year overall survival (OS) rate in Group PN and PS was 52.5% and 56.6%, respectively, also without a significant difference (p=0.748). The 5-year OS rate was inferior to the 5-year DFS rate in Group PS, and the 5-year OS rate was not better than the 5-year DFS rate in Group PN. The short-term results were better in Group PS than PN. However, the long-term results in both groups were similar. Other causes of death influenced OS in both groups; this result might have been affected by the surgical procedures.

Postpneumonectomy Compression of the Mitral Annulus: Rare Vascular Complication in Sportive Patient.

PubMed

Debeaumont, David; Bota, Susana; Baste, Jean-Marc; Bellefleur, Marie; Stepowski, Dimitri; Vincent, Florence; Bonnevie, Tristan; Gravier, Francis-Edouard; Netchitailo, Marie; Tardif, Catherine; Boutry, Alain; Muir, Jean-François; Coquart, Jérémy

2016-01-01

Numerous postpneumonectomy complications exist. We present a rare clinical case of postpneumonectomy exertional dyspnea revealing compression of the mitral annulus by the descending aorta. The patient was 42-year-old former smoker with pulmonary emphysema. He has been operated on, in 2012 (i.e., right pneumonectomy). Before the surgery, the patient was a recreational runner. However, after some months, it was difficult for the patient to resume running. Cardiopulmonary exercise testing indicated moderate exercise intolerance with important oxygen desaturation. More interestingly, a decrease of low oxygen pulse was noticed from the first ventilatory threshold with no electrical modification on the electrocardiogram. This decrease was indicative of a decline in stroke volume. The thoracic scan revealed a right pneumonectomy pocket with a liquid abnormal content. Moreover, the mediastinum had shifted toward the pneumonectomy space and the left lung was distended and emphysematous. Echocardiography revealed a major change in the mediastinal anatomy. The mitral annulus was observed to be compressed by the rear wall of the descending aorta. The diagnosis of postpneumonectomy syndrome or platypnea-orthodeoxia syndrome was ruled out in this patient. Mitral annular compression by the descending aorta is rare complication, which must be researched in patients with postpneumonectomy exertional dyspnea.

Postpneumonectomy Compression of the Mitral Annulus: Rare Vascular Complication in Sportive Patient

PubMed Central

Debeaumont, David; Bota, Susana; Baste, Jean-Marc; Bellefleur, Marie; Stepowski, Dimitri; Vincent, Florence; Bonnevie, Tristan; Gravier, Francis-Edouard; Netchitailo, Marie; Tardif, Catherine; Boutry, Alain; Muir, Jean-François

2016-01-01

Numerous postpneumonectomy complications exist. We present a rare clinical case of postpneumonectomy exertional dyspnea revealing compression of the mitral annulus by the descending aorta. The patient was 42-year-old former smoker with pulmonary emphysema. He has been operated on, in 2012 (i.e., right pneumonectomy). Before the surgery, the patient was a recreational runner. However, after some months, it was difficult for the patient to resume running. Cardiopulmonary exercise testing indicated moderate exercise intolerance with important oxygen desaturation. More interestingly, a decrease of low oxygen pulse was noticed from the first ventilatory threshold with no electrical modification on the electrocardiogram. This decrease was indicative of a decline in stroke volume. The thoracic scan revealed a right pneumonectomy pocket with a liquid abnormal content. Moreover, the mediastinum had shifted toward the pneumonectomy space and the left lung was distended and emphysematous. Echocardiography revealed a major change in the mediastinal anatomy. The mitral annulus was observed to be compressed by the rear wall of the descending aorta. The diagnosis of postpneumonectomy syndrome or platypnea-orthodeoxia syndrome was ruled out in this patient. Mitral annular compression by the descending aorta is rare complication, which must be researched in patients with postpneumonectomy exertional dyspnea. PMID:28116204

Sleeve lobectomy versus pneumonectomy for non-small cell lung cancer: a meta-analysis

PubMed Central

2012-01-01

Aim It is controversial that whether sleeve lobectomy (SL) should be promoted more worthy than pneumonectomy (PN) in suitable patients. Methods We searched all studies that had been published in English from PUBMED and Embase which compared the short-term and long-term outcomes of SL and pneumonectomy (PN) in patients with non-small cell lung cancer (NSCLC). Results Nineteen studies met our criteria with a combined total of 3878 subjects, of which 1316 (33.9%) underwent SL and 2562 (66.1%) underwent PN. The odds ratio was 0.50 (95% CI: 0.34-0.72) for postoperative mortality, 1.17 (95% CI: 0.82-1.67) for postoperative complications, 0.78 (95% CI: 0.47-1.29) for locoregional recurrences. The risk difference for 1-, 3-, 5- year was 0.11 (95% CI: 0.07-0.14), 0.15 (95% CI: 0.06-0.24), 0.15 (95% CI: 0.09-0.20),respectively. The pooled hazard ratio was 0.63 (95% CI: 0.56-0.71) in favor of SL group. Conclusion SL is more worthy to be done than PN in suitable patients with less mortality and better long-term survival. PMID:23231962

Early complications after pneumonectomy: retrospective study of 168 patients.

PubMed

Alloubi, Ihsan; Jougon, Jacques; Delcambre, Frédéric; Baste, Jean Marc; Velly, Jean François

2010-08-01

The purpose of this study was to assess the mortality and risk factors of complications after pneumonectomy for lung cancer. Between 1996 and 2001, we reviewed and analysed the demographic, clinical, functional, and surgical variables of 168 patients to identify risk factors of postoperative complications by univariate and multivariate analyses with Medlog software system. The mean age was 60+/-10 years, overall mortality and morbidity rates were 4.17% and 41.6%, respectively. All frequencies of respiratory complications were 1.2% for acute respiratory failure, 10.1% for pneumonia, 2.4% for acute pulmonary oedema, 4.17% for bronchopleural fistula, 2.4% for thoracic empyema and 18.5% for left recurrent nerve injuries. Postoperative arrhythmias developed in 46% of our patients. The risk factors for cardiopulmonary morbidity and mortality with univariate analysis were advanced age (P<0.01), preoperative poor performance status (P<0.015), and chronic artery disease (P<0.008). Factors adversely affecting morbidity with multivariate analysis included age (P=0.0001), associated cardiovascular disease (P=0.001), and altered forced expiratory volume in 1 s (P=0.0005). Complications after pneumonectomy are associated with high mortality. Careful attention must be paid to patients with advanced age and heart disease. Chest physiotherapy is paramount to have uneventful outcomes.

Postpneumonectomy syndrome in children: advantages and long-term follow-up of expandable prosthesis.

PubMed

Podevin, G; Larroquet, M; Camby, C; Audry, G; Plattner, V; Heloury, Y

2001-09-01

Pneumonectomy in children can be complicated by a severe mediastinal shift, which leads to bronchial stretching resulting in severe respiratory failure. This postpneumonectomy syndrome can be corrected by inserting a prosthesis in the empty side of the chest. Forty-two children, from 6 months to 15 years old, underwent a pneumonectomy. Seven of these patients were treated surgically for severe manifestations of postpneumonectomy syndrome. First insertion of an expandable prosthesis was followed up in 5 cases by its replacement with a breast prosthesis in adolescence. The expandable prosthesis was injected periodically with saline solution to maintain the mediastinum in a midline position as the children grew. The mean delay between pneumonectomy and first prosthesis implantation was 5 years (range, 11 months to 8 years). Pulmonary function tests showed a substantial improvement in the obstructive syndrome in all patients except one, in whom the functional improvement was moderate. The mean follow-up after the expandable prosthesis implantation was 6 years (range, 6 months to 10 years) and all patients are doing well. The insertion of an intrathoracic prosthesis can dramatically improve the clinical symptoms and reduce the functional obstructive syndrome. The expandable prosthesis allowed for progressive, well-tolerated recentering of the mediastinum and adjustment for growth. Copyright 2001 by W.B. Saunders Company.

Outcomes of Heimlich valve drainage in dogs.

PubMed

Salci, H; Bayram, A S; Gorgul, O S

2009-04-01

Retrospective study of the outcomes of Heimlich valve drainage in dogs. Medical records of the past 3 years were retrospectively reviewed. Heimlich valve drainage was used in 34 dogs (median body weight 30 +/- 5 kg): lobectomy (n = 15), pneumonectomy (n = 9), intrathoracic oesophageal surgery (n = 2), diaphragmatic hernia repair (n = 1), traumatic open pneumothorax (n = 2), bilobectomy (n = 2), ligation of the thoracic duct (n = 1), and chylothorax and pneumothorax (n = 1 each). Evacuation of air and/or fluid from the pleural cavity was performed with the Heimlich valve following thoracostomy tube insertion. During drainage, the dogs were closely monitored for possible respiratory failure. Termination of Heimlich valve drainage was controlled with underwater seal drainage and assessed with thoracic radiography. Negative intrathoracic pressure was provided in 29 dogs without any complications. Post pneumonectomy respiratory syncope and post lobectomy massive hemothorax, which did not originate from the Heimlich valve, were the only postoperative complications. Dysfunction of the valve diaphragm, open pneumothorax and intrathoracic localisation of an acute gastric dilatation-volvulus syndrome caused by a left-sided diaphragmatic hernia following pneumonectomy were the Heimlich valve drainage complications. The Heimlich valve can be used as a continuous drainage device in dogs, but the complications reported here should be considered by veterinary practitioners.

Lung surgery

MedlinePlus

... Lung tissue removal; Pneumonectomy; Lobectomy; Lung biopsy; Thoracoscopy; Video-assisted thoracoscopic surgery; VATS ... do surgery on your lungs are thoracotomy and video-assisted thoracoscopic surgery (VATS). Robotic surgery may also ...

Bronchial closure methods and risks for bronchopleural fistula in pulmonary resections: how a surgeon may choose the optimum method?

PubMed

Uçvet, Ahmet; Gursoy, Soner; Sirzai, Serdar; Erbaycu, Ahmet E; Ozturk, Ali A; Ceylan, Kenan C; Kaya, Seyda O

2011-04-01

There is debate about which bronchial closure technique is the best to prevent bronchopleural fistulas (BPFs). We aim to assess the effect of bronchial closure procedures and patients' characteristics on BPF occurrence in pulmonary resections. Bronchial closures in 625 consecutive patients were assessed. Stumps were closed by manual suturing in 204 and by mechanical stapling in 421 cases. In the mechanical stapling group, stapling supported by manual suture was performed in 170 cases. BPFs occurred in 3.8%. Of these, stapling was used in 5.0%, whereas manual suturing was used in 1.5% (P=0.04). BPFs were more prevalent among patients who had undergone pneumonectomy (P<0.01), right pneumonectomy (P<0.01), stapler closure (P<0.01), patients with co-factors (P<0.01), and patients who had undergone preoperative neo-adjuvant (P=0.01) or postoperative adjuvant therapy (P=0.03). There was no difference in the frequency of BPF between patients with and without adjuvant support in the stapling group. The optimum bronchial closure method has to be chosen by considering the patient and bronchus based characteristics. This has to be assessed carefully, especially in pneumonectomy and co-factors. The manual closure seems to be the more preferable method in risky patients. An additive support suture on the bronchial stump does not decrease the risk of BPF.

Completion pneumonectomy and chemoradiotherapy as treatment options in local recurrence of non-small-cell lung cancer

PubMed Central

Sławiński, Grzegorz; Musik, Martyna; Marciniak, Łukasz; Dyszkiewicz, Wojciech; Piwkowski, Cezary; Gałęcki, Bartłomiej

2015-01-01

Introduction The selection of treatment for local recurrence in patients with non-small-cell lung cancer (NSCLC) depends on the possibility of performing a radical tumor resection, the patient's performance status, and cardiopulmonary efficiency. Compared with chemoradiotherapy, surgical treatment offers a greater chance of long-term survival, but results in completion pneumonectomy and is associated with a relatively high rate of complications. Aim of the study Aim of the study was to evaluate early and long-term results of surgery and conservative treatment (chemoradiotherapy) in patients with local NSCLC recurrence. Material and methods Between 1998 and 2011, 1697 NSCLC patients underwent lobectomy or bilobectomy at the Department of Thoracic Surgery in Poznań. Among them, 137 patients (8.1%) were diagnosed with cancer recurrence; chemotherapy or chemoradiotherapy was provided to 116 patients; 21 patients (15.3%) were treated with completion pneumonectomy. The median time from primary surgery to recurrence was 13.4 months. No metastases to N2 lymph nodes were observed among the patients undergoing surgery; in 7 patients N1 lymph node metastases were confirmed. Results The rate of complications after surgery was significantly higher in comparison with conservative therapy (80.9% vs. 48.3%). Patients treated with surgery were most likely to suffer from complications associated with the circulatory system (80.9%), while hematologic complications were dominant in the group undergoing oncological treatment (41.4%). There were no perioperative deaths after completion pneumonectomy. The age of the patients was the only factor which significantly influenced the incidence of complications in both groups of patients. Analysis of the survival curves demonstrated statistically significant differences in survival between the groups treated with surgery, chemoradiotherapy, and chemotherapy (p = 0.00001). Five-year survival probability was significantly higher among patients treated surgically as compared to patients undergoing systemic therapy. Conclusions Despite the significant rate of postoperative complications (mostly circulatory), the long-term results of the surgical treatment of local NSCLC recurrence are more favorable than those achieved with chemoradiotherapy. The success of surgical treatment is conditioned on the exclusion of metastasis in N2 lymph nodes. PMID:26336473

Bronchial and bronchovascular sleeve resection for treatment of central lung tumors.

PubMed

Lausberg, H F; Graeter, T P; Wendler, O; Demertzis, S; Ukena, D; Schäfers, H J

2000-08-01

To improve postoperative pulmonary reserve, we have employed parenchyma-sparing resections for central lung tumors irrespective of pulmonary function. The results of lobectomy, pneumonectomy, and sleeve resection were analyzed retrospectively. From October 1995 to June 1999, 422 typical lung resections were performed for lung cancer. Of these, 301 were lobectomies (group I), 81 were sleeve resections (group II), and 40 were pneumonectomies (group III). Operative mortality was 2% in group I, 1.2% in group II, and 7.5% in group III (group I and II vs. group III, p<0.03). Mean time of intubation was 1.0+/-4.1 days in group I, 0.9+/-1.3 days in group II, and 3.6+/-11.2 days in group III (groups I and II vs. group III, p<0.01). The incidence of bronchial complications was 1.3% in group I, none in group II, and 7.5% in group III (group I and II vs group III, p<0.001). After 2 years, survival was 64% in group I, 61.9% in group II, and 56.1% in group III (p = NS). Freedom from local disease recurrence was 92.1% in group I, 95.7% in group II, and 90.9% in group III after 2 years (p = NS). Sleeve resection is a useful surgical option for the treatment of central lung tumors, thus avoiding pneumonectomy with its associated risks. Morbidity, early mortality, long-term survival, and recurrence of disease after sleeve resection are similar to those seen after lobectomy.

Surgery as an Adjunctive Treatment for Multidrug-Resistant Tuberculosis: An Individual Patient Data Metaanalysis.

PubMed

Fox, Gregory J; Mitnick, Carole D; Benedetti, Andrea; Chan, Edward D; Becerra, Mercedes; Chiang, Chen-Yuan; Keshavjee, Salmaan; Koh, Won-Jung; Shiraishi, Yuji; Viiklepp, Piret; Yim, Jae-Joon; Pasvol, Geoffrey; Robert, Jerome; Shim, Tae Sun; Shin, Sonya S; Menzies, Dick; Ahuja, S; Ashkin, D; Avendaño, M; Banerjee, R; Bauer, M; Burgos, M; Centis, R; Cobelens, F; Cox, H; D'Ambrosio, L; de Lange, W C M; DeRiemer, K; Enarson, D; Falzon, D; Flanagan, K; Flood, J; Gandhi, N; Garcia-Garcia, L; Granich, R M; Hollm-Delgado, M G; Holtz, T H; Hopewell, P; Iseman, M; Jarlsberg, L G; Kim, H R; Lancaster, J; Lange, C; Leimane, V; Leung, C C; Li, J; Menzies, D; Migliori, G B; Narita, M; Nathanson, E; Odendaal, R; O'Riordan, P; Pai, M; Palmero, D; Park, S K; Pena, J; Pérez-Guzmán, C; Ponce-de-Leon, A; Quelapio, M I D; Quy, H T; Riekstina, V; Royce, S; Salim, M; Schaaf, H S; Seung, K J; Shah, L; Shean, K; Sifuentes-Osornio, J; Sotgiu, G; Strand, M J; Sung, S W; Tabarsi, P; Tupasi, T E; Vargas, M H; van Altena, R; van der Walt, M; van der Werf, T S; Westenhouse, J; Yew, W W

2016-04-01

Medical treatment for multidrug-resistant (MDR)-tuberculosis is complex, toxic, and associated with poor outcomes. Surgical lung resection may be used as an adjunct to medical therapy, with the intent of reducing bacterial burden and improving cure rates. We conducted an individual patient data metaanalysis to evaluate the effectiveness of surgery as adjunctive therapy for MDR-tuberculosis. Individual patient data, was obtained from the authors of 26 cohort studies, identified from 3 systematic reviews of MDR-tuberculosis treatment. Data included the clinical characteristics and medical and surgical therapy of each patient. Primary analyses compared treatment success (cure and completion) to a combined outcome of failure, relapse, or death. The effects of all forms of resection surgery, pneumonectomy, and partial lung resection were evaluated. A total of 4238 patients from 18 surgical studies and 2193 patients from 8 nonsurgical studies were included. Pulmonary resection surgery was performed on 478 patients. Partial lung resection surgery was associated with improved treatment success (adjusted odds ratio [aOR], 3.0; 95% confidence interval [CI], 1.5-5.9; I(2)R, 11.8%), but pneumonectomy was not (aOR, 1.1; 95% CI, .6-2.3; I(2)R, 13.2%). Treatment success was more likely when surgery was performed after culture conversion than before conversion (aOR, 2.6; 95% CI, 0.9-7.1; I(2)R, 0.2%). Partial lung resection, but not pneumonectomy, was associated with improved treatment success among patients with MDR-tuberculosis. Although improved outcomes may reflect patient selection, partial lung resection surgery after culture conversion may improve treatment outcomes in patients who receive optimal medical therapy. © The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail journals.permissions@oup.com.

The Latest in Surgical Management of Stage IIIA Non-Small Cell Lung Cancer: Video-Assisted Thoracic Surgery and Tumor Molecular Profiling.

PubMed

Woodard, Gavitt A; Jablons, David M

2015-01-01

Stage IIIA non-small cell lung cancer (NSCLC) remains a treatment challenge and requires a multidisciplinary care team to optimize survival outcomes. Thoracic surgeons play an important role in selecting operative candidates and assisting with pathologic mediastinal staging via cervical mediastinoscopy, endobronchial ultrasound, or esophageal ultrasound with fine needle aspiration. The majority of patients with stage IIIA disease will receive induction therapy followed by repeat staging before undergoing lobectomy or pneumonectomy; occasionally, a patient with an incidentally found, single-station microscopic IIIA tumor will undergo resection as the primary initial therapy. Multiple large clinical trials, including SWOG-8805, EORTC-8941, INT-0139, and ANITA, have shown 5-year overall survival rates of up to 30% to 40% using triple-modality treatments, and the best outcomes repeatedly are seen among patients who respond to induction treatment or who have tumors amenable to lobectomy instead of pneumonectomy. The need for a pneumonectomy is not a reason to deny patients an operation, because current operative mortality and morbidity rates are acceptably low at 5% and 30%, respectively. In select patients with stage IIIA disease, video-assisted thoracic surgery and open resections have been shown to have comparable rates of local recurrence and long-term survival. New developments in genetic profiling and personalized medicine are exciting areas of research, and early data suggest that molecular profiling of stage IIIA NSCLC tumors can accurately stratify patients by risk within this stage and predict survival outcomes. Future advances in treating stage IIIA disease will involve developing better systemic therapies and customizing treatment plans on the basis of an individual tumor's genetic profile.

Pulmonary resections performed at hospitals with thoracic surgery residency programs have superior outcomes.

PubMed

Bhamidipati, Castigliano M; Stukenborg, George J; Ailawadi, Gorav; Lau, Christine L; Kozower, Benjamin D; Jones, David R

2013-01-01

Pulmonary resections are performed at thoracic residency (TR), general surgery residency (GSR), no surgery residency, and no residency hospitals. We hypothesize that morbidity and mortality for these procedures are different between hospitals and that operations performed at TR teaching hospitals have superior results. Records of adults who underwent pneumonectomy, lobar, segmentectomy, and nonanatomic wedge resections (N = 498,099) were evaluated in an all-payer inpatient database between 2003 and 2009. Hospital teaching status was determined by linkage to Association of American Medical College's Graduate Medical Education Tracking System. Multiple hierarchical regression models examined the in-hospital mortality, occurrence of any complication, and failure to rescue. The mean annual pulmonary resection volume among hospitals was TR (16%), GSR (17%), no surgery residency (28%), and no residency (39%). Unadjusted mortality for all procedures was lowest at TR hospitals (P < .001). Likewise, any complication was least likely to occur at TR hospitals (P < .001). After case-mix adjustment, the risk of any complication after segmentectomy or nonanatomic wedge resection was lower at TR hospitals than in GSR hospitals (P < .001). Among pneumonectomy recipients, TR hospitals reduced the adjusted odds ratio of failure to rescue by more than 25% compared with no surgery residency (P < .001). Likewise, in patients who underwent pneumonectomy, TR centers were associated with reducing the odds ratio of death by more than 30% compared with GSR hospitals (P < .001). In comparison with other hospitals, including GSR hospitals, TR hospitals have lower morbidity and mortality. These results support using hospitals with a TR as an independent prognostic indicator of outcomes in pulmonary resections. Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Mortality following single-fraction stereotactic body radiation therapy for central pulmonary oligometastasis

PubMed Central

Ma, Sung Jun; Mix, Michael; Rivers, Charlotte; Hennon, Mark; Gomez, Jorge

2017-01-01

The case of a 56-year-old male who developed bronchopulmonary hemorrhage after a course of stereotactic body radiation therapy (SBRT) for centrally located squamous cell lung carcinoma is presented. The patient was previously treated with concurrent chemoradiation for stage IVA squamous cell carcinoma of the base of tongue. He showed no evidence of disease for 4 years until he developed a solitary metastasis of squamous cell carcinoma in the right hilum. He underwent a single fraction of 26 Gy with heterogeneity correction. He showed no evidence of disease for 13 months until he developed a sudden grade 4 bronchopulmonary hemorrhage. He underwent an urgent right pneumonectomy and later died of a post-operative complication. Pathologic analysis of the specimen revealed no evidence of tumor. Single-fraction SBRT of 26 Gy was sufficient to achieve complete response of his large central lung tumor. However, when treating patients with central lung tumors, some risk of mortality may be unavoidable with either SBRT or pneumonectomy. PMID:29296456

Recruited Monocytes and Type 2 Immunity Promote Lung Regeneration following Pneumonectomy.

PubMed

Lechner, Andrew J; Driver, Ian H; Lee, Jinwoo; Conroy, Carmen M; Nagle, Abigail; Locksley, Richard M; Rock, Jason R

2017-07-06

To investigate the role of immune cells in lung regeneration, we used a unilateral pneumonectomy model that promotes the formation of new alveoli in the remaining lobes. Immunofluorescence and single-cell RNA sequencing found CD115+ and CCR2+ monocytes and M2-like macrophages accumulating in the lung during the peak of type 2 alveolar epithelial stem cell (AEC2) proliferation. Genetic loss of function in mice and adoptive transfer studies revealed that bone marrow-derived macrophages (BMDMs) traffic to the lung through a CCL2-CCR2 chemokine axis and are required for optimal lung regeneration, along with Il4ra-expressing leukocytes. Our data suggest that these cells modulate AEC2 proliferation and differentiation. Finally, we provide evidence that group 2 innate lymphoid cells are a source of IL-13, which promotes lung regeneration. Together, our data highlight the potential for immunomodulatory therapies to stimulate alveologenesis in adults. Copyright © 2017 Elsevier Inc. All rights reserved.

Polymeric films loaded with cisplatin for malignant pleural mesothelioma: a pharmacokinetic study in an ovine model

PubMed Central

Barocelli, Elisabetta; Cavazzoni, Andrea; Petronini, Piergiorgio; Mucchino, Claudio; Cantoni, Anna Maria; Leonardi, Fabio; Ventura, Luigi; Barbieri, Stefano; Colombo, Paolo; Fusari, Antonella; Carbognani, Paolo; Rusca, Michele; Sonvico, Fabio

2018-01-01

Background Malignant pleural mesothelioma (MPM) continues to be a distressing tumor due to its aggressive biologic behavior and scanty prognosis. Several therapeutic approaches have been tested both in clinical and preclinical settings, being intrapleural chemotherapy one of the most promising. Some years ago, our interest focused on polymeric films loaded with cisplatin for the adjuvant intrapleural treatment of surgical patients. After in vitro and in vivo studies in a rat recurrence model of MPM, the aim of this study was to evaluate the pharmacokinetics of the polymeric films in a sheep model in view of further studies in a clinical setting. Methods An ovine model was used. Animals were divided into four groups according to pharmacologic treatment: control group (three animals undergoing left pneumonectomy and saline-NaCl solution); intrapleural hyaluronate cisplatin films (HYALCIS) group (six animals undergoing left pneumonectomy and intrapleural application of polymeric films loaded with cisplatin); intrapleural cisplatin solution (six animals undergoing left pneumonectomy and intrapleural application of cisplatin solution); intravenous cisplatin (five animals undergoing left pneumonectomy and intravenous administration of cisplatin solution). The primary objective was the plasmatic and pleural concentration of cisplatin in the treatment groups. The secondary objective was the treatment-related toxicity evaluated by plasmatic analysis performed at prearranged time intervals and histological examinations of tissue samples collected during animal autopsy. Analysis of variance (ANOVA) was used for statistical analysis. Bonferroni correction was applied for comparison between all groups. Results Twenty female Sardinian sheep with a mean weight of 45.1 kg were studied. All animals survived the surgical procedures. The whole surgical procedure had a mean duration of 113 minutes. Cisplatin blood levels obtained from polymeric films application were low during the first 24 hours after the application; then, the cisplatin blood level increased gradually and progressively until it reached significantly higher plasmatic concentrations after 120 hours compared to intrapleural cisplatin solution (P=0.004) and intravenous administration (P=0.001), respectively. Considering cisplatin concentration at 168 hours after the application, animals treated with polymeric films had higher plasmatic values than animals treated with intrapleural cisplatin solution and intravenous cisplatin (P=0.001). Despite the high cisplatin plasmatic concentrations, treatment related-toxicity towards kidneys and liver was comparatively lower compared to the intravenous and intrapleural cisplatin administration and closer to the control levels. Conclusions Polymeric films loaded with cisplatin allowed to reach significantly higher intrapleural and plasmatic cisplatin concentrations compared to intrapleural and intravenous cisplatin solution, providing at the same time, a significant reduction of treatment related toxicity. PMID:29507788

Polymeric films loaded with cisplatin for malignant pleural mesothelioma: a pharmacokinetic study in an ovine model.

PubMed

Ampollini, Luca; Barocelli, Elisabetta; Cavazzoni, Andrea; Petronini, Piergiorgio; Mucchino, Claudio; Cantoni, Anna Maria; Leonardi, Fabio; Ventura, Luigi; Barbieri, Stefano; Colombo, Paolo; Fusari, Antonella; Carbognani, Paolo; Rusca, Michele; Sonvico, Fabio

2018-01-01

Malignant pleural mesothelioma (MPM) continues to be a distressing tumor due to its aggressive biologic behavior and scanty prognosis. Several therapeutic approaches have been tested both in clinical and preclinical settings, being intrapleural chemotherapy one of the most promising. Some years ago, our interest focused on polymeric films loaded with cisplatin for the adjuvant intrapleural treatment of surgical patients. After in vitro and in vivo studies in a rat recurrence model of MPM, the aim of this study was to evaluate the pharmacokinetics of the polymeric films in a sheep model in view of further studies in a clinical setting. An ovine model was used. Animals were divided into four groups according to pharmacologic treatment: control group (three animals undergoing left pneumonectomy and saline-NaCl solution); intrapleural hyaluronate cisplatin films (HYALCIS) group (six animals undergoing left pneumonectomy and intrapleural application of polymeric films loaded with cisplatin); intrapleural cisplatin solution (six animals undergoing left pneumonectomy and intrapleural application of cisplatin solution); intravenous cisplatin (five animals undergoing left pneumonectomy and intravenous administration of cisplatin solution). The primary objective was the plasmatic and pleural concentration of cisplatin in the treatment groups. The secondary objective was the treatment-related toxicity evaluated by plasmatic analysis performed at prearranged time intervals and histological examinations of tissue samples collected during animal autopsy. Analysis of variance (ANOVA) was used for statistical analysis. Bonferroni correction was applied for comparison between all groups. Twenty female Sardinian sheep with a mean weight of 45.1 kg were studied. All animals survived the surgical procedures. The whole surgical procedure had a mean duration of 113 minutes. Cisplatin blood levels obtained from polymeric films application were low during the first 24 hours after the application; then, the cisplatin blood level increased gradually and progressively until it reached significantly higher plasmatic concentrations after 120 hours compared to intrapleural cisplatin solution (P=0.004) and intravenous administration (P=0.001), respectively. Considering cisplatin concentration at 168 hours after the application, animals treated with polymeric films had higher plasmatic values than animals treated with intrapleural cisplatin solution and intravenous cisplatin (P=0.001). Despite the high cisplatin plasmatic concentrations, treatment related-toxicity towards kidneys and liver was comparatively lower compared to the intravenous and intrapleural cisplatin administration and closer to the control levels. Polymeric films loaded with cisplatin allowed to reach significantly higher intrapleural and plasmatic cisplatin concentrations compared to intrapleural and intravenous cisplatin solution, providing at the same time, a significant reduction of treatment related toxicity.

[Successful One-lung Ventilation with a Right-sided Double-lumen Tube in a Patient with a Right Upper Tracheal Bronchus, who Underwent Left Pneumonectomy for Left Hilar Lung Cancer].

PubMed

Kawagoe, Izumi; Kohchiyama, Tsukasa; Hayashida, Masakazu; Satoh, Daizoh; Suzuki, Kenji; Inada, Eiichi

2016-06-01

A 60-year-old male patient with left hilar lung cancer was scheduled to undergo left pneumonectomy or left sleeve lower lobectomy. Preoperative computer tomographic and bronchoscopic examinations revealed that the bronchus (B1) to the right apical segment (S1) was a tracheal bronchus (TB) originating from the trachea approximately 10 mm above the carina. Because the left main bronchus was to be dissected, a right-sided double-lumen tube (DLT) was selected to completely protect the right lung from spillage of secretions or cancer cells from the left lung. The right-sided DLT was placed so as to fit its lateral opening of the bronchial lumen to normal upper branches (B2, B3), while sacrificing ventilation of S1 with an abnormal branch (B1). However, one-lung ventilation (OLV) of the right lung could not be achieved, since a gas leakage from the opened tracheal lumen occurred, most probably due to intra-lobar micro-airway communications between S1 and S2/S3. The DLT was withdrawn until the blue bronchial cuff occluded the orifice of the TB (B1). Although the upper half of the blue bronchial cuff appeared above the tracheal carina, OLV through the two bronchial lumen openings could be achieved due to a specific, slanted doughnut shape of the blue bronchial cuff and the location of the abnormal branch (B1) approximate to the carina. Left pneumonectomy using successful OLV was completed safely without hypoxemia or hypercapnea. Our experience indicates that management of OLV for patients with a thoracheal bronchus needs special considerations of the exact location of the TB and intra-lobar micro-airway communications, in addition to types of scheduled surgical procedures.

Dose-Dependent Pulmonary Toxicity After Postoperative Intensity-Modulated Radiotherapy for Malignant Pleural Mesothelioma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Rice, David C.; Smythe, W. Roy; Liao Zhongxing

Purpose: To determine the incidence of fatal pulmonary events after extrapleural pneumonectomy and hemithoracic intensity-modulated radiotherapy (IMRT) for malignant pleural mesothelioma. Methods and Materials: We retrospectively reviewed the records of 63 consecutive patients with malignant pleural mesothelioma who underwent extrapleural pneumonectomy and IMRT at University of Texas M. D. Anderson Cancer Center. The endpoints studied were pulmonary-related death (PRD) and non-cancer-related death within 6 months of IMRT. Results: Of the 63 patients, 23 (37%) had died within 6 months of IMRT (10 of recurrent cancer, 6 of pulmonary causes [pneumonia in 4 and pneumonitis in 2], and 7 of othermore » noncancer causes [pulmonary embolus in 2, sepsis after bronchopleural fistula in 1, and cause unknown but without pulmonary symptoms or recurrent disease in 4]). On univariate analysis, the factors that predicted for PRD were a lower preoperative ejection fraction (p = 0.021), absolute volume of lung spared at 10 Gy (p = 0.025), percentage of lung volume receiving {>=}20 Gy (V{sub 20}; p 0.002), and mean lung dose (p = 0.013). On multivariate analysis, only V{sub 20} was predictive of PRD (p = 0.017; odds ratio, 1.50; 95% confidence interval, 1.08-2.08) or non-cancer-related death (p = 0.033; odds ratio, 1.21; 95% confidence interval, 1.02-1.45). Conclusion: The results of our study have shown that fatal pulmonary toxicities were associated with radiation to the contralateral lung. V{sub 20} was the only independent determinant for risk of PRD or non-cancer-related death. The mean V{sub 20} of the non-PRD patients was considerably lower than that accepted during standard thoracic radiotherapy, implying that the V{sub 20} should be kept as low as possible after extrapleural pneumonectomy.« less

Intensity-Modulated Radiotherapy for Resected Mesothelioma: The Duke Experience

DOE Office of Scientific and Technical Information (OSTI.GOV)

Miles, Edward F.; Larrier, Nicole A.; Kelsey, Christopher R.

2008-07-15

Purpose: To assess the safety and efficacy of intensity-modulated radiotherapy (IMRT) after extrapleural pneumonectomy for malignant pleural mesothelioma. Methods and Materials: Thirteen patients underwent IMRT after extrapleural pneumonectomy between July 2005 and February 2007 at Duke University Medical Center. The clinical target volume was defined as the entire ipsilateral hemithorax, chest wall incisions, including drain sites, and involved nodal stations. The dose prescribed to the planning target volume was 40-55 Gy (median, 45). Toxicity was graded using the modified Common Toxicity Criteria, and the lung dosimetric parameters from the subgroups with and without pneumonitis were compared. Local control and survivalmore » were assessed. Results: The median follow-up after IMRT was 9.5 months. Of the 13 patients, 3 (23%) developed Grade 2 or greater acute pulmonary toxicity (during or within 30 days of IMRT). The median dosimetric parameters for those with and without symptomatic pneumonitis were a mean lung dose (MLD) of 7.9 vs. 7.5 Gy (p = 0.40), percentage of lung volume receiving 20 Gy (V{sub 20}) of 0.2% vs. 2.3% (p = 0.51), and percentage of lung volume receiving 5 Gy (V{sub 20}) of 92% vs. 66% (p = 0.36). One patient died of fatal pulmonary toxicity. This patient received a greater MLD (11.4 vs. 7.6 Gy) and had a greater V{sub 20} (6.9% vs. 1.9%), and V{sub 5} (92% vs. 66%) compared with the median of those without fatal pulmonary toxicity. Local and/or distant failure occurred in 6 patients (46%), and 6 patients (46%) were alive without evidence of recurrence at last follow-up. Conclusions: With limited follow-up, 45-Gy IMRT provides reasonable local control for mesothelioma after extrapleural pneumonectomy. However, treatment-related pulmonary toxicity remains a significant concern. Care should be taken to minimize the dose to the remaining lung to achieve an acceptable therapeutic ratio.« less

Prevalence and Predictors of Neoadjuvant Therapy for Stage IIIA Non-Small Cell Lung Cancer in the National Cancer Database: Importance of Socioeconomic Status and Treating Institution

DOE Office of Scientific and Technical Information (OSTI.GOV)

Sher, David J., E-mail: david_sher@rush.edu; Liptay, Michael J.; Fidler, Mary Jo

Purpose: The optimal locoregional therapy for stage IIIA non-small cell lung cancer (NSCLC) is controversial, with definitive chemoradiation therapy (CRT) and neoadjuvant therapy followed by surgery (NT-S) serving as competing strategies. In this study, we used the National Cancer Database to determine the prevalence and predictors of NT in a large, modern cohort of patients. Methods and Materials: Patients with stage IIIA NSCLC treated with CRT or NT-S between 2003 and 2010 at programs accredited by the Commission on Cancer were included. Predictors were categorized as clinical, time/geographic, socioeconomic, and institutional. In accord with the National Cancer Database, institutions were classifiedmore » as academic/research program and as comprehensive and noncomprehensive community cancer centers. Logistic regression and random effects multilevel logistic regression were performed for univariable and multivariable analyses, respectively. Results: The cohort consisted of 18,581 patients, 3,087 (16.6%) of whom underwent NT-S (10.6% induction CRT, 6% induction chemotherapy). The prevalence of NT-S was constant over time, but there were significant relative 31% and 30% decreases in pneumonectomy and right-sided pneumonectomy, respectively, over time (P trend <.02). In addition to younger age, lower T stage, and favorable comorbidity score, indicators of higher socioeconomic status were strong independent predictors of NT-S, including white race, higher income, and private/managed insurance. The type of institution (academic/research program vs comprehensive or noncomprehensive community cancer centers, odds ratio 1.54 and 2.08, respectively) strongly predicted NT-S, but treatment volume did not. Conclusions: Neoadjuvant therapy followed by surgery was an uncommon treatment approach in Commission on Cancer programs, and the prevalence of postinduction pneumonectomy decreased over time. Higher socioeconomic status and treatment at academic institutions were significant predictors of NT-S. Further research should be performed to enable a better understanding of these disparities.« less

Carinal resection, left pneumonectomy, and right lung anastomosis for adenocystic basal cell carcinoma (cylindroma)

PubMed Central

Thompson, Douglas T.; Doyle, Jorge A.; Roncoroni, Aquiles J.

1969-01-01

The surgical approach to, and resection of, a cylindroma of the left main bronchus involving the trachea and right main bronchus is described. The literature on bronchial adenoma and cylindroma is reviewed, both the pathogenesis and surgery being discussed. A plea for a more aggressive approach is made. Images PMID:4310817

Pulmonary function tests in the preoperative evaluation of lung cancer surgery candidates. A review of guidelines.

PubMed

Trzaska-Sobczak, Marzena; Skoczyński, Szymon; Pierzchała, Władysław

2014-09-01

Before planned surgical treatment of lung cancer, the patient's respiratory system function should be evaluated. According to the current guidelines, the assessment should start with measurements of FEV1 (forced expiratory volume in 1 second) and DLco (carbon monoxide lung diffusion capacity). Pneumonectomy is possible when FEV1 and DLco are > 80% of the predicted value (p.v.). If either of these parameters is < 80%, an exercise test with VO2 max (oxygen consumption during maximal exercise) measurement should be performed. When VO2 max is < 35 % p.v. or < 10 ml/kg/min, resection is associated with high risk. If VO2 max is in the range of 35-75% p.v. or 10-20 ml/kg/min, the postoperative values of FEV1 and DLco (ppoFEV1, ppoDLco) should be determined. The exercise test with VO2 max measurement may be replaced with other tests such as the shuttle walk test and the stair climbing test. The distance covered during the shuttle walk test should be > 400 m. Patients considered for lobectomy should be able to climb 3 flights of stairs (12 m) and for pneumonectomy 5 flights of stairs (22 m).

Lineage Analysis in Pulmonary Arterial Hypertension

DTIC Science & Technology

2012-06-01

undergo pneunomectomy followed one week later by intravenous injection of monocrotaline pyrrole . The fate of GFP-expressing cells of endothelial lineage...pneumonectomy followed one week later by jugular vein injection of monocrotaline pyrrole in dimethyl formamide. Expression of smooth muscle alpha actin in...cells. We induced experimental pulmonary hypertension in SM22 Cre x mT/mG mice, by injecting monocrotaline pyrrole into the pulmonary circulation of

Unusual late presentation of metastatic extrathoracic thymoma to gastrohepatic lymph node treated by surgical resection.

PubMed

Billè, Andrea; Sachidananda, Sandeep; Moreira, Andre L; Rizk, Nabil P

2017-02-01

In advanced stages, thymic tumors tend to spread locally. Distant metastatic disease is rare. We present the first report of single metastatic abdominal lymph node in a 37-year-old female patient and 5 years after an extrapleural pneumonectomy for stage IV thymoma followed by radiotherapy with no other evidence of abdominal disease successfully treated by robotic surgical resection.

An adult case of giant bronchogenic cyst mimicking tension pneumothorax.

PubMed

Yalcinkaya, Serhat; Vural, A Hakan; Ozal, Hasan

2010-10-01

Bronchogenic cysts are usually discovered only incidentally in the adult. A giant bronchogenic cyst in a 19-year-old woman presenting with pain and shortness of breath was mistaken for tension pneumothorax and initially treated with tube thoracostomy. Giant bullae were diagnosed by computed tomography. Bullae resection was undertaken, but the remaining lung tissue required pneumonectomy. Pathologic examination of the specimen confirmed bronchogenic cyst.

The effects of lung resection on physiological motor activity of the oesophagus.

PubMed

Fiorelli, Alfonso; Vicidomini, Giovanni; Milione, Roberta; Grassi, Roberto; Rotondo, Antonio; Santini, Mario

2013-08-01

To assess the modifications of oesophageal function after major lung resection and whether these modifications are correlated with the extent of resection (pneumonectomy vs others). In the last 5 years, 40 consecutive surgical patients with lung cancer were prospectively enrolled and divided in two groups: Group A (n = 20) patients scheduled for elective pneumonectomy and Group B (n = 20) for more limited resections (lobectomy or bilobectomy). In addition to routine evaluations, all patients underwent preoperative (within 5 days) and postoperative (6 months) oesophageal manometry to assess the lower oesophageal sphincter (LES), the oesophageal body and the upper oesophageal sphincter functions. Symptoms scoring questionnaires were recorded for each patient and the oesophageal dislocation assessed by radiological examinations. Thirty-three (15 of Group A and 18 of Group B) patients completed the study. After operation, we found that LES resting pressure was significantly lower in Group A compared with Group B (P = 0.01); conversely, the relaxing pressure resulted as being higher in Group A than in Group B (P = 0.01). In Group A compared with Group B, a significant reduction of amplitude and that of wave duration of oesophageal contractions were seen at the upper (0.0001 and 0.02, respectively), middle (0.0003 and 0.002, respectively) and lower (0.0001 and 0.0004, respectively) oesophageal body. In addition, 12 of 15 (80%) patients of Group A and 3 of 18 (17%) of Group B presented a lack of regular peristaltic movement (P = 0.001). Despite chest CT scan showing a shift of the oesophagus in 11 of 15 (73%) and 2 of 18 (11.1%) patients of Groups A and B (P = 0.001), the oesophagus dislocation resulted 'severe' on barium swallow study in only two patients of Group A. The manometric alterations were subclinical; heartburn was recorded in three patients (two of Group A and one of Group B) and epigastric pain in four (two for each group). No other symptoms were observed. Pneumonectomy may cause significant oesophageal motility disorders that are mostly subclinical. Thus, this type of surgery should not be denied to patients if required to treat their cancer.

Prognostic Score of Long-Term Survival After Surgery for Malignant Pleural Mesothelioma: A Multicenter Analysis.

PubMed

Leuzzi, Giovanni; Rea, Federico; Spaggiari, Lorenzo; Marulli, Giuseppe; Sperduti, Isabella; Alessandrini, Gabriele; Casiraghi, Monica; Bovolato, Pietro; Pariscenti, Gianluca; Alloisio, Marco; Infante, Maurizio; Pagan, Vittore; Fontana, Paolo; Oliaro, Alberto; Ruffini, Enrico; Ratto, Giovanni Battista; Leoncini, Giacomo; Sacco, Rocco; Mucilli, Felice; Facciolo, Francesco

2015-09-01

Despite ongoing efforts to improve therapy in malignant pleural mesothelioma, few patients undergoing extrapleural pneumonectomy experience long-term survival (LTS). This study aims to explore predictors of LTS after extrapleural pneumonectomy and to define a prognostic score. From January 2000 to December 2010, we retrospectively reviewed clinicopathologic and oncological factors in a multicenter cohort of 468 malignant pleural mesothelioma patients undergoing extrapleural pneumonectomy. LTS was defined as survival longer than 3 years. Associations were evaluated using χ(2), Student's t, and Mann-Whitney U tests. Logistic regression, Cox regression hazard model, and bootstrap analysis were applied to identify outcome predictors. Survival curves were calculated by the Kaplan-Meier method. Receiver operating characteristic analyses were used to estimate optimal cutoff and area under the curve for accuracy of the model. Overall, 107 patients (22.9%) survived at least 3 years. Median overall, cancer-specific, and disease-free survival times were 60 (95% confidence interval [CI], 51 to 69), 63 (95% CI, 54 to 72), and 49 months (95% CI, 39 to 58), respectively. At multivariate analysis, age (odds ratio, 0.51; 95% CI, 0.31 to 0.82), epithelioid histology (odds ratio, 7.07; 95% CI, 1.56 to 31.93), no history of asbestos exposure (odds ratio, 3.13; 95% CI, 1.13 to 8.66), and the ratio between metastatic and resected lymph nodes less than 22% (odds ratio, 4.12; 95% CI, 1.68 to 10.12) were independent predictors of LTS. According to these factors, we created a scoring system for LTS that allowed us to correctly predict overall, cancer-specific, and disease-free survival in the total sample, obtaining two different groups with favorable or poor prognosis (area under the curve, 0.74; standard error, 0.04; p < 0.0001). Our prognostic model facilitates the prediction of LTS after surgery for malignant pleural mesothelioma and can help to stratify the outcome and, eventually, tailor postoperative treatment. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

WE-AB-BRA-06: 4DCT-Ventilation: A Novel Imaging Modality for Thoracic Surgical Evaluation

DOE Office of Scientific and Technical Information (OSTI.GOV)

Vinogradskiy, Y; Jackson, M; Schubert, L

Purpose: The current standard-of-care imaging used to evaluate lung cancer patients for surgical resection is nuclear-medicine ventilation. Surgeons use nuclear-medicine images along with pulmonary function tests (PFT) to calculate percent predicted postoperative (%PPO) PFT values by estimating the amount of functioning lung that would be lost with surgery. 4DCT-ventilation is an emerging imaging modality developed in radiation oncology that uses 4DCT data to calculate lung ventilation maps. We perform the first retrospective study to assess the use of 4DCT-ventilation for pre-operative surgical evaluation. The purpose of this work was to compare %PPO-PFT values calculated with 4DCT-ventilation and nuclear-medicine imaging. Methods:more » 16 lung cancer patients retrospectively reviewed had undergone 4DCTs, nuclear-medicine imaging, and had Forced Expiratory Volume in 1 second (FEV1) acquired as part of a standard PFT. For each patient, 4DCT data sets, spatial registration, and a density-change based model were used to compute 4DCT-ventilation maps. Both 4DCT and nuclear-medicine images were used to calculate %PPO-FEV1 using %PPO-FEV1=pre-operative FEV1*(1-fraction of total ventilation of resected lung). Fraction of ventilation resected was calculated assuming lobectomy and pneumonectomy. The %PPO-FEV1 values were compared between the 4DCT-ventilation-based calculations and the nuclear-medicine-based calculations using correlation coefficients and average differences. Results: The correlation between %PPO-FEV1 values calculated with 4DCT-ventilation and nuclear-medicine were 0.81 (p<0.01) and 0.99 (p<0.01) for pneumonectomy and lobectomy respectively. The average difference between the 4DCT-ventilation based and the nuclear-medicine-based %PPO-FEV1 values were small, 4.1±8.5% and 2.9±3.0% for pneumonectomy and lobectomy respectively. Conclusion: The high correlation results provide a strong rationale for a clinical trial translating 4DCT-ventilation to the surgical domain. Compared to nuclear-medicine, 4DCT-ventilation is cheaper, does not require a radioactive contrast agent, provides a faster imaging procedure, and has improved spatial resolution. 4DCT-ventilation can reduce the cost and imaging time for patients while providing improved spatial accuracy and quantitative results for surgeons. YV discloses grant from State of Colorado.« less

Comparative analysis of the mechanical signals in lung development and compensatory growth.

PubMed

Hsia, Connie C W

2017-03-01

This review compares the manner in which physical stress imposed on the parenchyma, vasculature and thorax and the thoraco-pulmonary interactions, drive both developmental and compensatory lung growth. Re-initiation of anatomical lung growth in the mature lung is possible when the loss of functioning lung units renders the existing physiologic-structural reserves insufficient for maintaining adequate function and physical stress on the remaining units exceeds a critical threshold. The appropriate spatial and temporal mechanical interrelationships and the availability of intra-thoracic space, are crucial to growth initiation, follow-on remodeling and physiological outcome. While the endogenous potential for compensatory lung growth is retained and may be pharmacologically augmented, supra-optimal mechanical stimulation, unbalanced structural growth, or inadequate remodeling may limit functional gain. Finding ways to optimize the signal-response relationships and resolve structure-function discrepancies are major challenges that must be overcome before the innate compensatory ability could be fully realized. Partial pneumonectomy reproducibly removes a known fraction of functioning lung units and remains the most robust model for examining the adaptive mechanisms, structure-function consequences and plasticity of the remaining functioning lung units capable of regeneration. Fundamental mechanical stimulus-response relationships established in the pneumonectomy model directly inform the exploration of effective approaches to maximize compensatory growth and function in chronic destructive lung diseases, transplantation and bioengineered lungs.

Post-recurrence chemotherapy for mesothelioma patients undergoing extrapleural pneumonectomy.

PubMed

Takuwa, Teruhisa; Hashimoto, Masaki; Matsumoto, Seiji; Kondo, Nobuyuki; Kuribayash, Kozo; Nakano, Takashi; Hasegawa, Seiki

2017-10-01

Additional chemotherapy is often not feasible in patients with recurrent malignant pleural mesothelioma (MPM) undergoing extrapleural pneumonectomy (EPP), due to deteriorated cardiopulmonary reserve. We thus examined the feasibility and efficacy of additional chemotherapy in patients with recurrent MPM after EPP. A retrospective review was conducted of 59 consecutive patients who underwent bi-/tri-modal treatment with induction chemotherapy, EPP, and radiation therapy from July 2004 to August 2013 at Hyogo College of Medicine (Nishinomiya, Japan). Of 59 patients, 39 (male/female = 31/8, right/left = 15/24, pathological stage I/II/III/IV = 1/7/23/3, bi-/tri-modality = 27/12) relapsed at a median age of 62 (range 37-71) years. The median time to recurrence after EPP was 11.6 months. Of the 39 relapsed patients, 12 received best supportive care alone, six started but discontinued chemotherapy, and the remaining 21 (53%) completed more than three cycles of intravenous chemotherapy. The median survival time after EPP was significantly longer in 21 patients who received additional chemotherapy than in 18 patients who did not (39.2 vs. 12.2 months, P = 0.009). Additional systemic chemotherapy was successfully administered in more than 50% of relapsed patients after bi-/tri-modal treatment, which included EPP, and resulted in a longer survival in comparison with best supportive care alone.

Comparative Analysis of the Mechanical Signals in Lung Development and Compensatory Growth

PubMed Central

Hsia, Connie C.W.

2017-01-01

This review compares the manner in which physical stress imposed on the parenchyma, vasculature and thorax, and the thoraco-pulmonary interactions, drive both developmental and compensatory lung growth. Re-initiation of anatomical lung growth in the mature lung is possible when the loss of functioning lung units renders the existing physiologic-structural reserves insufficient for maintaining adequate function and physical stress on the remaining units exceeds a critical threshold. The appropriate spatial and temporal mechanical interrelationships, and the availability of intra-thoracic space, are crucial to growth initiation, follow-on remodeling and physiological outcome. While the endogenous potential for compensatory lung growth is retained and may be pharmacologically augmented, supra-optimal mechanical stimulation, unbalanced structural growth, or inadequate remodeling, may limit functional gain. Finding ways to optimize the signal-response relationships and resolve structure-function discrepancies are major challenges that must be overcome before the innate compensatory ability could be fully realized. Partial pneumonectomy reproducibly removes a known fraction of functioning lung units and remains the most robust model for examining the adaptive mechanisms, structure-function consequences, and plasticity of the remaining functioning lung units capable of regeneration. Fundamental mechanical stimulus-response relationships established in the pneumonectomy model directly inform the exploration of effective approaches to maximize compensatory growth and function in chronic destructive lung diseases, transplantation and bioengineered lungs. PMID:28084523

An unusual case of spontaneous esophagopleural fistula.

PubMed

Dash, Manoranjan; Mohanty, Thitta; Patnaik, Jyoti; Mishra, Narayan; Subhankar, Saswat; Parida, Priyadarsini

2017-01-01

Esophago-pleural fistula (EPF) is an uncommon condition, despite of an anatomical proximity of these structures. Causes of EPF include pneumonectomy for suppurative or tubercular disease of lung and carcinoma lung, malignancy of esophagus. Benign EPF is rare and may be due to trauma or infection. The most common infectious cause is tuberculosis. Spontaneous development of fistula between esophagus and pleura is rarely described in literature. We, hereby present a spontaneous case of such a rare entity in a middle-aged male.

An unusual case of spontaneous esophagopleural fistula

PubMed Central

Dash, Manoranjan; Mohanty, Thitta; Patnaik, Jyoti; Mishra, Narayan; Subhankar, Saswat; Parida, Priyadarsini

2017-01-01

Esophago-pleural fistula (EPF) is an uncommon condition, despite of an anatomical proximity of these structures. Causes of EPF include pneumonectomy for suppurative or tubercular disease of lung and carcinoma lung, malignancy of esophagus. Benign EPF is rare and may be due to trauma or infection. The most common infectious cause is tuberculosis. Spontaneous development of fistula between esophagus and pleura is rarely described in literature. We, hereby present a spontaneous case of such a rare entity in a middle-aged male. PMID:28474659

A Comparative Evaluation of Mechanical Suturing of the Bronchial Stump with the UKB-25 and UKL-60 Apparatuses in Experimental Pneumonectomies

DTIC Science & Technology

1960-09-27

carried out; the processing differed for each of the series» The first series comprised 25 experiments. After tying the vessels, the stitchers of...the exposure of the pulmonary radix pulmonis, the stitchers of the apparatus were placed on the radix pulmonis as close to the bi- furcation as...at the level of the stitchers , and the lung was removed„ The hermeticity was then checked and the stump was dusted with penicillin. Fifteen

Intraoperative Recurrent Laryngeal Nerve Monitoring in a Patient with Contralateral Vocal Fold Palsy.

PubMed

Na, Bub-Se; Choi, Jin-Ho; Park, In Kyu; Kim, Young Tae; Kang, Chang Hyun

2017-10-01

Recurrent laryngeal nerve injury can develop following cervical or thoracic surgery; however, few reports have described intraoperative recurrent laryngeal nerve monitoring. Consensus regarding the use of this technique during thoracic surgery is lacking. We used intraoperative recurrent laryngeal nerve monitoring in a patient with contralateral vocal cord paralysis who was scheduled for completion pneumonectomy. This case serves as an example of intraoperative recurrent laryngeal nerve monitoring during thoracic surgery and supports this indication for its use.

Aortobronchial fistula caused by an endobronchial lobar Y stent: a word of caution.

PubMed

Härting, Margarete; Welter, Stefan; Aigner, Clemens

2018-04-25

A 17-year-old female patient with a history of pulmonary tuberculosis was admitted with progressive dyspnoea and haemoptysis. Five months prior to admission, a left bronchial carina Y stent was implanted. Because of the already destroyed parenchyma, a pneumonectomy was planned. Intraoperatively, an aortobronchial fistula was discovered as the source of bleeding, which could be stopped by pledget-armed sutures. The formation of an aortobronchial fistula has to be considered as a potential source of endobronchial bleeding after stent implantation.

One-stoma carinoplasty: right upper sleeve lobectomy with hemicarinectomy for resection of right-tracheobronchial-angle tumors.

PubMed

Kaya, Seyda Ors; Sevinc, Serpil; Ceylan, Kenan Can; Usluer, Ozan; Unsal, Saban

2013-01-01

Tracheobronchial-angle tumors involve the right main bronchus, the right upper lobar bronchus, and the lateral wall of the lower trachea. Resecting these tumors is one of the most complex procedures in thoracic surgery. In cases of high-caliber mismatch, the selection of a suitable anastomotic technique can be challenging. We found that our use of a one-stoma carinoplasty technique overcame high-caliber mismatch after the resection of these tumors. From 2009 through 2012, 8 men (mean age, 59 ± 6.2 yr; range, 46-66 yr) underwent complete resection of non-small-cell right-tracheobronchial-angle tumors at our institution. In every case, right upper sleeve lobectomy, wedge carinal resection, and one-stoma carinoplasty were applied. After tumor resection, one patient with hemoptysis and bronchopleural fistula underwent a completion pneumonectomy and died 10 days postoperatively. Bronchoscopy was necessary in 2 patients who had atelectasis in the contralateral lung. At a mean follow-up duration of 19.43 ± 8.4 months (range, 0.2-27.1 mo), 6 patients were alive and free of disease. We conclude that our one-stoma carinoplasty technique enables the resection of tumors at the right tracheobronchial angle, with acceptable morbidity and mortality rates. This method saves the unaffected part of the ipsilateral lung and can overcome high-caliber mismatch. Because of these and other advantages, we suggest that using our method first might preclude having to perform a right carinal sleeve pneumonectomy or using Barclay's method.

Aeromedical transport of a patient with massive chylothorax following pneumonectomy for mesothelioma.

PubMed

Deviri, Ehud; Caine, Yehezkel; Henig-Hadar, Avinoam; Saute, Milton; Ish Tov, Eytan

2009-11-01

Long-distance transportation of a patient in an unstable condition is a challenging operation. When circumstances require using a commercial flight it is even more so. A 57-yr-old man in Israel underwent extrapleural pneumonectomy for mesothelioma, following which he developed a massive chylothorax of more than 6 L x d(-1). Due to the failure of medical treatment and the high operative risk under such conditions, it was decided to transfer him to the United States by commercial flight for a percutaneous, fluoroscopy-guided closure of the thoracic duct. The patient was accompanied by a physician and a nonmedical assistant and occupied a first-class seat enclosed by curtains. He arrived at the departure airport in a hypovolemic state with low cardiac output and blood pressure of 78/60 Torr. During the flight he was treated with intravenous fluids, chest physiotherapy, and oxygen. In addition, fibrin clots blocked the drainage system on two occasions, requiring corrective action. On arrival in the United States the patient's condition had improved: his blood pressure was 123/91 Torr with a capillary oxygen saturation of 95% without supplementary oxygen. During the 18 h in transit (11 h in flight) he had lost more than 5 L of lymph. Under carefully controlled circumstances it is possible to use commercial flights to transport patients whose condition is unstable and complicated. Safety can be increased by focusing on the specific problems associated with the clinical condition and anticipating possible adverse events during the flight.

Time trend in the surgical therapy of lung cancer.

PubMed

Stolz, A; Pafko, P; Lischke, R; Harustiak, T; Simonek, J; Schutzner, J; Adamek, S

2011-01-01

The purpose of our study was to clarify results of surgery for non-small cell lung cancer (NSCLC) and its time trends. We retrospectively reviewed our prospective database of patients who underwent surgery for NSCLC between 1998 and 2009 in our institution. Patients were divided into two equal 6-year periods according to the year of surgery (1998-2003 and 2004-2009). One thousand, four hundred and twelve patients underwent operation for NSCLC. We performed 985 lobectomies with 30-days mortality of 1.8 % and 300 pneumonectomies with 30-days mortality of 5.7 %. Median of survival of all 1412 patients was 4.3 year and 5-year survival was 45 %. The percentage of female patients, lobectomies and adenocarcinomas increased over time, as well as the age of our patients. Outcome improved over time, with significant decrease in a 30-days mortality after pneumonectomy (8.2 % vs 2.3 %, p=0.029). The overall 3-year survival improved in patients with stage III (30 % vs 40 %, p=0.012). Outcomes of lung resection for NSCLC improved over time despite a worsening of some elements of preoperative status. The shift in histological distribution was associated with an increasing proportion of patients with stage I, a lower operative mortality and better 3- and 5-year survival. These trends are due to improvement of preoperative evaluation, preoperative and postoperative care (Tab. 1, Fig. 2, Ref. 9). Full Text in free PDF www.bmj.sk.

[Surgical treatment of pulmonary metastases from colon and rectal cancer].

PubMed

Togashi, Ken-ichi; Aoki, K; Hirahara, H; Sugawara, M; Oguma, F

2004-09-01

We retrospectively studied the surgical treatment for pulmonary metastases from colon and rectal cancer. A total of 24 patients (9 males and 15 females; mean age 61 years) underwent 29 thoracotomies for metastatic colon carcinoma, while 22 patients (16 males and 6 females; mean age 63 years) underwent 29 thoracotomies for metastatic rectal cancer. The median interval between the primary procedure and lung resection for metastases was 26 months in the patients with colon carcinoma and 32 months in the patients with rectal cancer. In the patients with colon carcinoma, 16 underwent wedge resection or segmentectomy (including 4 video-assisted procedures) and 13 (54%) underwent lobectomy or pneumonectomy. In the patients with rectal cancer, 15 underwent wedge or segmentectomy (including 1 video-assisted procedure), 13 (59%) underwent lobectomy or pneumonectomy, and 1 underwent exploratory thoracotomy. All procedures except exploratory thoracotomy were curative operations. There was no mortality. Overall 5-year survival was 56% (n=46). Five-year survival was 65% for patients with colon metastases (n=24) and 45% for patients with rectal metastases (n=22), and there was no significant difference. Recurrent sites were 4 lungs (36%), 4 livers (36%), 1 bone, 1 uterus, and 1 peritoneum in patients with colon carcimoma, and 10 lungs (43%), 5 brains (22%), 3 livers (13%), 1 bone, and 1 vagina in patients with rectal cancer. Pulmonary resection for metastases from colon carcinoma may have better prognosis than that from rectal cancer. However, further investigation may be required to obtain convincing conclusions.

Retinoic acid-induced alveolar cellular growth does not improve function after right pneumonectomy.

PubMed

Dane, D Merrill; Yan, Xiao; Tamhane, Rahul M; Johnson, Robert L; Estrera, Aaron S; Hogg, Deborah C; Hogg, Richard T; Hsia, Connie C W

2004-03-01

To determine whether all-trans retinoic acid (RA) treatment enhances lung function during compensatory lung growth in fully mature animals, adult male dogs (n = 4) received 2 mg x kg(-1) x day(-1) po RA 4 days/wk beginning the day after right pneumonectomy (R-PNX, 55-58% resection). Litter-matched male R-PNX controls (n = 4) received placebo. After 3 mo, transpulmonary pressure (TPP)-lung volume relationship, diffusing capacities for carbon monoxide and nitric oxide, cardiac output, and septal volume (V(tiss-RB)) were measured under anesthesia by a rebreathing technique at two lung volumes. Lung air and tissue volumes (V(air-CT) and V(tiss-CT)) were also measured from high-resolution computerized tomographic (CT) scans at a constant TPP. In RA-treated dogs compared with controls, TPP-lung volume relationships were similar. Diffusing capacities for carbon monoxide and nitric oxide were significantly impaired at a lower lung volume but similar at a high lung volume. Whereas V(tiss-RB) was significantly lower at both lung volumes in RA-treated animals, V(air-CT) and V(tiss-CT) were not different between groups; results suggest uneven distribution of ventilation consistent with distortion of alveolar geometry and/or altered small airway function induced by RA. We conclude that RA does not improve resting pulmonary function during the early months after R-PNX despite histological evidence of its action in enhancing alveolar cellular growth in the remaining lung.

Determining the appropriate sleeve lobectomy versus pneumonectomy ratio in central non-small cell lung cancer patients: an audit of an aggressive policy of pneumonectomy avoidance.

PubMed

Gómez-Caro, Abel; Garcia, Samuel; Reguart, Noemí; Cladellas, Esther; Arguis, Pedro; Sanchez, Marcelo; Gimferrer, Josep Maria

2011-03-01

To study the outcomes of broncho ± angioplastic sleeve lobectomy (SL) versus pneumonectomy (PN), and the PN:SL ratio after an aggressive policy of parenchyma-sparing surgery to improve postoperative complications rate and long-term quality of life (QoL). A prospective study was conducted in 490 patients with non-small cell lung cancer between 2005 and 2009. All patients not suitable for standard lobectomy were scheduled for SL, if possible, or for PN; eight patients with functional impairment were directly scheduled for SL. Of 76 procedures, 21 (4%) were PN and 55 (11%) SL (29 bronchoplastic, seven bronchovascular, seven angioplastic; 11 extended to more than one lobe). There were no surgical, oncological or physiological preoperative differences between the groups. The 5-year PN:SL ratio was 1:2.6 (2005: 1:2.1; 2006: 1:2.6; 2007: 1:3.6; 2008: 1:3; 2009: 1:3.5). SL and PN mortality were 2 (3.6%) and 1 (5%), respectively. Postoperative complications occurred in 18 (32%) SL and 7 (33%) PN patients. pN1 (p = 0.04), vascular reconstruction and upper-left SL were risk factors for postoperative complications of SL (p = 0.03) but were not detected as a mortality risk. Overall 5-year survival was 61% for SL and 31% for PN. Survival at 5 years was significantly higher for SL (p = 0.03, Kaplan-Meier). Age <70 years and SL were positive factors for long-term survival. In multivariate modelling, both remained positive factors. Surviving PN patients experienced significantly greater loss of respiratory function and lower QoL than those who avoided this surgery (preoperative score, PN vs SL: 52 vs 51; 3 months, 41 vs 43; and 6 months, 42 vs 51, p = 0.04). The adjuvant treatment complement was higher in SL at 34 (62%) than at PN 10 (47%). The side effects of this treatment were more frequent in patients with more extirpated parenchyma (p = 0.04). Parenchyma-sparing procedures can reduce the PN rate to less than 10%. A PN:SL index lower than 1:1.5 as a quality standard in a specialised thoracic unit should encourage the use of broncho-angioplastic procedures and improve patient outcomes. Long-term survival, QoL, postoperative lung function test and tolerance of adjuvant therapies are significantly better after SL than PN intervention. Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Postoperative Radiotherapy in the Management of Resected Non-Small-Cell Lung Carcinoma: 10 Years' Experience in a Single Institute

DOE Office of Scientific and Technical Information (OSTI.GOV)

Karakoyun-Celik, Omur, E-mail: okarakoyuncelik@yahoo.co; Yalman, Deniz; Bolukbasi, Yasemin

2010-02-01

Purpose: This study reports the long term outcomes of postoperative radiotherapy in patients with resection for non-small-cell lung cancer (NSCLC). Methods and Materials: A total of 98 patients with resected NSCLC who received postoperative radiotherapy (PORT) between January 1994 and December 2004 were retrospectively analyzed. The most frequently performed surgical procedure was lobectomy (59 patients), followed by pneumonectomy (25), wedge resection (8), and bilobectomy (6). Postoperative radiotherapy was delivered as an adjuvant treatment in 71 patients, after a wedge resection in 8 patients, and after an R1 resection in 19 patients. The PORT was administered using a Co-60 source inmore » 86 patients and 6-MV photons in 12 patients. A Kaplan-Meier estimate of overall survival, locoregional control, and distant metastasis-free survival were calculated. Results: Stages included I (n =13), II (n = 50), IIIA (n = 29), and IIIB (n = 6). After a median follow-up of 52 months median survival was 61 months. The 5-year overall survival, locoregional control, and distant metastasis-free survival rates for the whole group were 50%, 78%, and 55% respectively. The RT dose, Karnofsky performance status, age, lateralization of the tumor, and pneumonectomy were independent prognostic factors for OAS; anemia and the number of involved lymph nodes were independent prognostic factors for LC. Conclusions: Doses of PORT of greater than 54 Gy were associated with higher death rate in patients with left-sided tumor, which may indicate a risk of radiation-induced cardiac mortality.« less

[Place of bilobectomy in pulmonary oncology and prognostic factors in NSCLC].

PubMed

Arame, A; Rivera, C; Pricopi, C; Mordant, P; Abdennadher, M; Foucault, C; Dujon, A; Le Pimpec Barthes, F; Riquet, M

2014-10-01

Bilobectomy may be performed for different reasons and lung tumors. There are still controversies regarding the results of this procedure. We reviewed our experience of bilobectomy to evaluate the particularities of this resection. The clinical files of patients operated on for lung tumors in two French centers between 1980 and 2009 were prospectively recorded and retrospectively analyzed. The characteristics, management, pathology, and survival after right-sided resections for non-small cell lung cancer (NSCLC) were then compared. During the study period, 3280 right-sided resections were performed, including 235 bilobectomy (7%), for NSCLC in 192 cases (82%). Lower-middle lobectomy (LML) represented 60% of bilobectomy, with carcinoid tumors and squamous cell carcinoma being more frequent in this group. Upper-middle lobectomy (UML) represented 40% of bilobectomy, with less postoperative complications and mortality in this group. In N0-NSCLC, the rate of postoperative mortality and 5-year survival rates after bilobectomy (4.7% and 46.1%, respectively) were intermediate between lobectomy (2.7% and 52.6%) and pneumonectomy (9.6% and 31.7%, P<10(-6) for both comparisons). There was no significant difference in 5-year survival rates according to the type of bilobectomy and the performance of any induction therapy. Bilobectomy is associated with acceptable in-hospital mortality and encouraging 5-year survival rates despite an increased incidence of postoperative complications. Approximation in survival of UML and pneumonectomy and of LML and lobectomy may be due to differences in histologic features with different fissure extension and interlobar node involvement. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

Perfusion-related stimuli for compensatory lung growth following pneumonectomy

PubMed Central

Dane, D. Merrill; Yilmaz, Cuneyt; Gyawali, Dipendra; Iyer, Roshni; Ravikumar, Priya; Estrera, Aaron S.

2016-01-01

Following pneumonectomy (PNX), two separate mechanical forces act on the remaining lung: parenchymal stress caused by lung expansion, and microvascular distension and shear caused by increased perfusion. We previously showed that parenchymal stress and strain explain approximately one-half of overall compensation; the remainder was presumptively attributed to perfusion-related factors. In this study, we directly tested the hypothesis that perturbation of regional pulmonary perfusion modulates post-PNX lung growth. Adult canines underwent banding of the pulmonary artery (PAB) to the left caudal (LCa) lobe, which caused a reduction in basal perfusion to LCa lobe without preventing the subsequent increase in its perfusion following right PNX while simultaneously exaggerating the post-PNX increase in perfusion to the unbanded lobes, thereby creating differential perfusion changes between banded and unbanded lobes. Control animals underwent sham pulmonary artery banding followed by right PNX. Pulmonary function, regional pulmonary perfusion, and high-resolution computed tomography of the chest were analyzed pre-PNX and 3-mo post-PNX. Terminally, the remaining lobes were fixed for detailed morphometric analysis. Results were compared with corresponding lobes in two control (Sham banding and normal unoperated) groups. PAB impaired the indices of post-PNX extravascular alveolar tissue growth by up to 50% in all remaining lobes. PAB enhanced the expected post-PNX increase in alveolar capillary formation, measured by the prevalence of double-capillary profiles, in both unbanded and banded lobes. We conclude that perfusion distribution provides major stimuli for post-PNX compensatory lung growth independent of the stimuli provided by lung expansion and parenchymal stress and strain. PMID:27150830

A phase I study of Foscan-mediated photodynamic therapy and surgery in patients with mesothelioma.

PubMed

Friedberg, Joseph S; Mick, Rosemarie; Stevenson, James; Metz, James; Zhu, Timothy; Buyske, Jo; Sterman, Daniel H; Pass, Harvey I; Glatstein, Eli; Hahn, Stephen M

2003-03-01

Photodynamic therapy (PDT) is a light-based cancer treatment that, in the correct setting, can be delivered intraoperatively as an adjuvant therapy. A phase I clinical trial combining surgical debulking with Foscan-mediated PDT was performed in patients with malignant pleural mesothelioma. The purpose of the study was to define the toxicities and to determine the maximally tolerated dose (MTD) of Foscan-mediated PDT. A total of 26 patients completed treatment. Tumor debulking was accomplished with either an extrapleural pneumonectomy (7 patients) or a lung-sparing pleurectomy-decortication (19 patients). Patients were injected with Foscan before surgery, and 652 nm light was delivered intraoperatively after completion of surgical debulking. Four light sensors were placed in the chest, allowing delivery of light to a uniform measured dose throughout the hemithorax. Four dose levels were explored. The MTD was 0.1 mg/kg of Foscan injected 6 days before surgery in combination with 10 J x cm(-2) 652 nm light. Dose limiting toxicity at the next higher dose was a systemic capillary leak syndrome leading to death in 2 of 3 patients treated at that dose. Other PDT-related toxicities included wound burns and skin photosensitivity. In all, 14 patients were treated at the MTD without significant complications. Foscan-mediated PDT can be safely combined with surgery at the established MTD. Unlike most other surgery-based multimodal treatments for mesothelioma, Foscan-mediated PDT affords the option, in selected patients, of accomplishing tumor debulking with a lung-sparing procedure rather than an extrapleural pneumonectomy. A phase II study is warranted.

Clinical value of CT-based preoperative software assisted lung lobe volumetry for predicting postoperative pulmonary function after lung surgery

NASA Astrophysics Data System (ADS)

Wormanns, Dag; Beyer, Florian; Hoffknecht, Petra; Dicken, Volker; Kuhnigk, Jan-Martin; Lange, Tobias; Thomas, Michael; Heindel, Walter

2005-04-01

This study was aimed to evaluate a morphology-based approach for prediction of postoperative forced expiratory volume in one second (FEV1) after lung resection from preoperative CT scans. Fifteen Patients with surgically treated (lobectomy or pneumonectomy) bronchogenic carcinoma were enrolled in the study. A preoperative chest CT and pulmonary function tests before and after surgery were performed. CT scans were analyzed by prototype software: automated segmentation and volumetry of lung lobes was performed with minimal user interaction. Determined volumes of different lung lobes were used to predict postoperative FEV1 as percentage of the preoperative values. Predicted FEV1 values were compared to the observed postoperative values as standard of reference. Patients underwent lobectomy in twelve cases (6 upper lobes; 1 middle lobe; 5 lower lobes; 6 right side; 6 left side) and pneumonectomy in three cases. Automated calculation of predicted postoperative lung function was successful in all cases. Predicted FEV1 ranged from 54% to 95% (mean 75% +/- 11%) of the preoperative values. Two cases with obviously erroneous LFT were excluded from analysis. Mean error of predicted FEV1 was 20 +/- 160 ml, indicating absence of systematic error; mean absolute error was 7.4 +/- 3.3% respective 137 +/- 77 ml/s. The 200 ml reproducibility criterion for FEV1 was met in 11 of 13 cases (85%). In conclusion, software-assisted prediction of postoperative lung function yielded a clinically acceptable agreement with the observed postoperative values. This method might add useful information for evaluation of functional operability of patients with lung cancer.

[Operative treatment and remote results in patients with bronchoalveolar lung cancer].

PubMed

Uchikov, A; Batashki, I; Dimitrov, I; Uchikova, E; Belovezhdov, V; Bonev, P

2008-01-01

Bronchoalveolar pulmonary carcinoma (BAC) is a type of adenocarcinoma with an increasing frequency. Because BAC rarely metastasize outside the thorax, the postoperative results are good. We present 28 patients with BAC, operated in the clinic for a period of 7 years--12 patients with an infiltrative form of BAC, 16 patients with nodular form 12 patients underwent lobectomy, 15 patients--pneumonectomy, and 1 patient--bilobectomy. The 5-years-survival rate is 50%. We found a better 5-years survival rate for the patients with BAC in comparison with the other histological types of non-small cell pulmonary carcinoma

Aggressive Surgical Resection of Pulmonary Artery Intimal Sarcoma.

PubMed

Yamamoto, Yoko; Shintani, Yasushi; Funaki, Soichiro; Taira, Masaki; Ueno, Takayoshi; Kawamura, Tomohiro; Kanzaki, Ryu; Minami, Masato; Sawa, Yoshiki; Okumura, Meinoshin

2018-05-03

Intimal sarcoma of the pulmonary artery is a rare and highly malignant neoplasm. We herein report a case of a 30-year-old woman with an extensive right pulmonary artery tumor who underwent an emergent operation. The tumor was aggressively resected with right pneumonectomy and reconstruction of the right ventricle outflow tract and left pulmonary artery. Although the resected margin at the left pulmonary artery was positive, as confirmed by Mouse double minute type 2 homolog staining, she is doing well and remains free of relapse at 16 months after the operation. Copyright © 2018. Published by Elsevier Inc.

Trimodality strategy for treating malignant pleural mesothelioma: results of a feasibility study of induction pemetrexed plus cisplatin followed by extrapleural pneumonectomy and postoperative hemithoracic radiation (Japan Mesothelioma Interest Group 0601 Trial).

PubMed

Hasegawa, Seiki; Okada, Morihito; Tanaka, Fumihiro; Yamanaka, Takeharu; Soejima, Toshinori; Kamikonya, Norihiko; Tsujimura, Tohru; Fukuoka, Kazuya; Yokoi, Kohei; Nakano, Takashi

2016-06-01

We conducted a prospective multi-institutional study to determine the feasibility of trimodality therapy (TMT) comprising induction chemotherapy followed by extrapleural pneumonectomy (EPP) and radiation therapy in Japanese patients with malignant pleural mesothelioma (MPM). Major eligibility criteria were histologically confirmed diagnosis of MPM, including clinical subtypes T0-3, N0-2, M0 disease; no prior treatment for the disease; age 20-75 years; Eastern Cooperative Oncology Group performance status 0 or 1; predicted postoperative forced expiratory volume >1000 ml in 1 s; written informed consent. Treatment methods comprised induction chemotherapy using pemetrexed (500 mg/m(2)) plus cisplatin (60 mg/m(2)) for three cycles, followed by EPP and postoperative hemithoracic radiation therapy (54 Gy). Primary endpoints were macroscopic complete resection (MCR) rate for EPP and treatment-related mortality for TMT. Forty-two eligible patients were enrolled: median age 64.5 (range 43-74) years; M:F = 39:3, clinical stage I:II:III = 14:13:15; histological type epithelioid were sarcomatoid; biphasic; others = 28:1:9:4. Of 42 patients, 30 completed EPP with MCR and 17 completed TMT. The trial met the primary endpoints, with an MCR rate of 71 % (30/42) and treatment-related mortality of 9.5 % (4/42). Overall median survival time and 2-year survival rate for 42 registered patients were 19.9 months and 42.9 %, respectively. Two-year relapse-free survival rate of 30 patients who completed EPP with MCR was 37.0 %. This phase II study met the predefined primary endpoints, but its risk/benefit ratio was not satisfactory.

Extrapleural pneumonectomy for malignant mesothelioma: an Italian multicenter retrospective study.

PubMed

Spaggiari, Lorenzo; Marulli, Giuseppe; Bovolato, Pietro; Alloisio, Marco; Pagan, Vittore; Oliaro, Alberto; Ratto, Giovanni Battista; Facciolo, Francesco; Sacco, Rocco; Brambilla, Daniela; Maisonneuve, Patrick; Mucilli, Felice; Alessandrini, Gabriele; Leoncini, Giacomo; Ruffini, Enrico; Fontana, Paolo; Infante, Maurizio; Pariscenti, Gian Luca; Casiraghi, Monica; Rea, Federico

2014-06-01

This study assessed perioperative outcome and long-term survival in a large series of patients with malignant pleural mesothelioma who underwent extrapleural pneumonectomy (EPP) to identify prognostic factors allowing better patient selection. We retrospectively collected data from nine referral centers for thoracic surgery in Italy. Perioperative outcome and survival data were available for 518 malignant pleural mesothelioma patients (84.4% with epithelial tumors, 68.0% with pathologic stage 3 disease) who underwent EPP with intention-to-treat (R0/R1) between 2000 and 2010. Induction chemotherapy was administered in 271 patients (52.3%) and adjuvant therapy in 373 patients (72.0%), including radiotherapy in 213 patients (41.1%), adjuvant chemotherapy in 43 patients (8.3%), and both in 117 patients (22.6%). In all, 136 patients (26.3%) had major complications after EPP, and 36 (6.9%) died within 90 days after surgery. The median overall survival was 18 months, with a 1-, 2-, and 3-year overall survival of 65%, 41%, and 27%, respectively. At multivariable analysis adjusted for age and disease stage, male sex (hazard ratio [HR] 1.47, 95% confidence interval [CI]: 1.12 to 1.92), nonepithelial histology (HR 1.96, 95% CI: 1.48 to 2.58), and trimodality treatment using induction chemotherapy (HR 0.61, 95% CI: 0.43 to 0.85) were significantly associated with survival. Development of a major complication also significantly worsened outcome (HR 1.85, 95% CI: 1.37 to 2.50). The success of EPP in the context of a multimodality treatment depends on a series of patient characteristics. Female patients, patients with epithelial tumors, and patients who received induction chemotherapy will best benefit from EPP. Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

[The randomized study of efficiency of preoperative photodynamic].

PubMed

Akopov, A L; Rusanov, A A; Molodtsova, V P; Gerasin, A V; Kazakov, N V; Urtenova, M A; Chistiakov, I V

2013-01-01

The authors made a prospective randomized comparison of results of preoperative photodynamic therapy (PhT) with chemotherapy, preoperative chemotherapy in initial unresectable central non-small cell lung cancer in stage III. The efficiency and safety of preoperative therapy were estimated as well as the possibility of subsequent surgical treatment. The research included patients in stage IIIA and IIIB of central non-small cell lung cancer with lesions of primary bronchi and lower section of the trachea, which initially were unresectable, but potentially the patients could be operated on after preoperative treatment. The photodynamic therapy was performed using chlorine E6 and the light of wave length 662 nm. Since January 2008 till December 2011,42 patients were included in the research, 21 patients were randomized in the group for photodynamic therapy and 21--in group without PhT. These groups were compared according to their sex, age, stage of the disease and histological findings. After nonadjuvant treatment the remissions were reached in 19 (90%) patients of the group with PhT and in 16 (76%) patients without PhT and all the patients were operated on. The explorative operations were made on 3 patients out of 16 operated on in the group without PhT (19%). In the group PhT 14 pneumonectomies and 5 lobectomies were perfomed opposite 10 pneumonectomies and 3 lobectomies in group without PhT. The degree of radicalism of resection appears to be reliably higher in the group PhT (RO-89%, R1-11% as against RO-54%, R1-46% in group without PhT), p = 0.038. The preoperative endobronchial PhT conducted with chemotherapy was characterized by efficiency and safety, allowed the surgical treatment and elevated the degree of radicalism of this treatment in selected patients, initially assessed as unresectable.

Restricted Field IMRT Dramatically Enhances IMRT Planning for Mesothelioma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Allen, Aaron M.; Schofield, Deborah; Hacker, Fred

2007-12-01

Purpose: To improve the target coverage and normal tissue sparing of intensity-modulated radiotherapy (IMRT) for mesothelioma after extrapleural pneumonectomy. Methods and Materials: Thirteen plans from patients previously treated with IMRT for mesothelioma were replanned using a restricted field technique. This technique was novel in two ways. It limited the entrance beams to 200{sup o} around the target and three to four beams per case had their field apertures restricted down to the level of the heart or liver to further limit the contralateral lung dose. New constraints were added that included a mean lung dose of <9.5 Gy and volumemore » receiving {>=}5 Gy of <55%. Results: In all cases, the planning target volume coverage was excellent, with an average of 97% coverage of the planning target volume by the target dose. No change was seen in the target coverage with the new technique. The heart, kidneys, and esophagus were all kept under tolerance in all cases. The average mean lung dose, volume receiving {>=}20 Gy, and volume receiving {>=}5 Gy with the new technique was 6.6 Gy, 3.0%, and 50.8%, respectively, compared with 13.8 Gy, 15%, and 90% with the previous technique (p < 0.0001 for all three comparisons). The maximal value for any case in the cohort was 8.0 Gy, 7.3%, and 57.5% for the mean lung dose, volume receiving {>=}20 Gy, and volume receiving {>=}5 Gy, respectively. Conclusion: Restricted field IMRT provides an improved method to deliver IMRT to a complex target after extrapleural pneumonectomy. An upcoming Phase I trial will provide validation of these results.« less

Chronological changes in lung cancer surgery in a single Japanese institution

PubMed Central

Nakamura, Haruhiko; Sakai, Hiroki; Kimura, Hiroyuki; Miyazawa, Tomoyuki; Marushima, Hideki; Saji, Hisashi

2017-01-01

Background The aim of this study was to evaluate the chronological changes in epidemiological factors and surgical outcomes in patients with lung cancer who underwent surgery in a single Japanese institution. Patients and methods A clinicopathological database of patients with lung cancer who underwent surgery with curative intent from January 1974 to December 2014 was reviewed. The chronological changes in various factors, including patient’s age, sex, histological type, tumor size, pathological stage (p-stage), surgical method, operative time, intraoperative blood loss, 30-day mortality, and postoperative overall survival (OS), were evaluated. Results A total of 1,616 patients were included. The numbers of resected patients, females, adenocarcinomas, p-stage IA patients, and age at the time of surgery increased with time, but tumor size decreased (all P<0.0001). Concerning surgical methods, the number of sublobar resections increased, but that of pneumonectomies decreased (P<0.0001). The mean operative time, intraoperative blood loss, and the postoperative 30-day mortality rate decreased (all P<0.0001). When the patients were divided into two groups (1974–2004 and 2005–2014), the 5-year OS rates for all patients and for p-stage IA patients improved from 44% to 79% and from 73% to 89%, respectively (all P<0.0001). The best 5-year OS rate was obtained for sublobar resection (73%), followed by lobectomy (60%), combined resection (22%), and pneumonectomy (21%; P<0.0001). Conclusion Changes in epidemiological factors, a trend toward less invasive surgery, and a remarkably improved postoperative OS were confirmed, which demonstrated the increasingly important role of surgery in therapeutic strategies for lung cancer. PMID:28331339

Bronchial and arterial sleeve resection for centrally-located lung cancers

PubMed Central

D’Andrilli, Antonio; Venuta, Federico; Rendina, Erino Angelo

2016-01-01

The use of bronchial and arterial sleeve resections for the treatment of centrally-located lung cancers, when available, has become the option of choice in comparison with pneumonectomy (PN). Technical expertise, in particular in vascular reconstruction, and perioperative management improved over time allowing excellent short-term and long-term results. This is even truer if considering literature data from the main experiences published in the last years. These evidences have given to such lung sparing reconstructive procedures more and more acceptance among the surgical community. This article focuses on the main technical aspects and literature data regarding bronchovascular sleeve resections. PMID:27942409

Chylothorax: diagnosis by lipoprotein electrophoresis of serum and pleural fluid.

PubMed Central

Seriff, N S; Cohen, M L; Samuel, P; Schulster, P L

1977-01-01

This report describes a 31-year-old woman who underwent a technically difficult left pneumonectomy for tuberculosis and developed thereafter a large left pleural effusion which was milky in colour. A traumatic chylothorax was suspected, and the diagnosis was confirmed by simultaneous fasting pleural and serum lipid studies and lipoprotein electrophoresis. The latter study was especially helpful in confirming the chylous nature of the fluid in that it revealed a marked chylomicron band at the origin; this was not present in the patient's serum nor in the pleural fluid of five patients with other disease states studied as controls. Images PMID:841541

The value of Asamura-Naruke type main bronchus stump closure and pleuro-pericardial flap covering by own method to avoid broncho-pleural fistula (BPF).

PubMed

Kecskés, L; Bátori, G; Gehér, P; Kiss, B

1999-01-01

1. Authors present an "old-new" main bronchus closure procedure, which combines the Sweet's and Overholt's methods, recommended by Asamura-Naruke. 2. The A-N procedure decreased the prevalence of BPF from 2.8% to 0.09% in case of thoracotomy and from 9.5% to 2.4% in case of pneumonectomy compared 2 different stump-closing types. 3. There was not BPF in the "covered subgroup" (0%/92 PN) recommended by us, independent of the closing types. 4. All bronchial stumps closed like A-N and covered by our method (0% BPF/62 PN) healed.

Right pneumonectomy for carcinoid tumor extending through the intermediate bronchus and the interlobar artery.

PubMed

Elkhayat, Hussein; Gonzalez-Rivas, Diego

2016-01-01

Uniportal video-assisted thoracic surgery (VATS) is the emerging technique in the modern thoracic surgery practice in Assiut University Hospitals in Egypt we try to keep up with the cutting edge of knowledge to deliver the best available service to our patient. So we invite Dr. Diego Gonzalez-Rivas the world pioneer surgeon in uniportal VATS approach to initiate a uniportal VATS program starting with a workshop with live surgery. The workshop was attended by 84 thoracic surgeons from all across Egypt with a high motivation for adopting the technique in the everyday practice. We believe that uniportal will be the first choice approach for thoracic surgeon in Egypt in the upcoming year.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Rosenzweig, Kenneth E., E-mail: ken.rosenzweig@mountsinai.org; Zauderer, Marjorie G.; Laser, Benjamin

Purpose: In patients with malignant pleural mesothelioma who are unable to undergo pneumonectomy, it is difficult to deliver tumoricidal radiation doses to the pleura without significant toxicity. We have implemented a technique of using intensity-modulated radiotherapy (IMRT) to treat these patients, and we report the feasibility and toxicity of this approach. Methods and Materials: Between 2005 and 2010, 36 patients with malignant pleural mesothelioma and two intact lungs (i.e., no previous pneumonectomy) were treated with pleural IMRT to the hemithorax (median dose, 46.8 Gy; range, 41.4-50.4) at Memorial Sloan-Kettering Cancer Center. Results: Of the 36 patients, 56% had right-sided tumors.more » The histologic type was epithelial in 78%, sarcomatoid in 6%, and mixed in 17%, and 6% had Stage I, 28% had Stage II, 33% had Stage III, and 33% had Stage IV. Thirty-two patients (89%) received induction chemotherapy (mostly cisplatin and pemetrexed); 56% underwent pleurectomy/decortication before IMRT and 44% did not undergo resection. Of the 36 patients evaluable for acute toxicity, 7 (20%) had Grade 3 or worse pneumonitis (including 1 death) and 2 had Grade 3 fatigue. In 30 patients assessable for late toxicity, 5 had continuing Grade 3 pneumonitis. For patients treated with surgery, the 1- and 2-year survival rate was 75% and 53%, and the median survival was 26 months. For patients who did not undergo surgical resection, the 1- and 2-year survival rate was 69% and 28%, and the median survival was 17 months. Conclusions: Treating the intact lung with pleural IMRT in patients with malignant pleural mesothelioma is a safe and feasible treatment option with an acceptable rate of pneumonitis. Additionally, the survival rates were encouraging in our retrospective series, particularly for the patients who underwent pleurectomy/decortication. We have initiated a Phase II trial of induction chemotherapy with pemetrexed and cisplatin with or without pleurectomy/decortication, followed by pleural IMRT to prospectively evaluate the toxicity and survival.« less

Transcatheter Closure of Patent Foramen Ovale in Patients with Platypnea-Orthodeoxia: Results of a Multicentric French Registry

DOE Office of Scientific and Technical Information (OSTI.GOV)

Guerin, P.; Lambert, V.; Godart, F.

Background. Dyspnea and the decrease in arterial saturation in the upright position in elderly subjects is described as platypnea-orthodeoxia syndrome (POS). POS is secondary to the occurrence of an atrial right-to-left shunt through a patent foramen ovale (PFO). Methods. This French multicentric study reports on 78 patients (mean age 67 {+-} 11.3 years) with POS who had transcatheter closure of the PFO; frequently associated diseases were pneumonectomy (n = 36) and an ascending aortic aneurysm (n = 11). In all patients, the diagnosis was confirmed by transthoracic or/and transesophageal echocardiography. Five different closure devices were used: Amplatz (n = 45),more » Cardioseal (n = 13), Sideris (n = 11), Das Angel Wings (n = 8) and Starflex (n = 1). Closure was successful in 76 patients (97%). Results. Oxygen saturation increased immediately after occlusion from 84.6 {+-} 10.7% to 95.1 {+-} 6.4% (p < 0.001) and dyspnea improved from grade 2.7 {+-} 0.7 to grade 1 {+-} 1 (p < 0.001). A small residual shunt was immediately observed in 5 patients (3 with the Cardioseal device, 1 with the Sideris and 1 with the Amplatz) leading to the implantation of a second device in one case (Cardioseal). Two early deaths occurred unrelated to the procedure (one due to sepsis probably related to pneumonectomy, another due to respiratory insufficiency). Other complications were: a small shunt between the aorta and the left atrium, two atrial fibrillations and a left-sided thrombus which disappeared with anticoagulant therapy. At a mean follow-up of 15 {+-} 12 months, there were 7 late deaths related to the underlying disease. Conclusion. Percutaneous occlusion of the foramen ovale is safe and gives excellent results thanks to continuing improvement in available devices. This technique enables some patients in an unstable condition to avoid a surgical closure.« less

Neoadjuvant treatment followed by surgery versus definitive chemoradiation in stage IIIA-N2 non-small-cell lung cancer: A multi-institutional study by the oncologic group for the study of lung cancer (Spanish Radiation Oncology Society).

PubMed

Couñago, F; Rodriguez de Dios, N; Montemuiño, S; Jové-Teixidó, J; Martin, M; Calvo-Crespo, P; López-Mata, M; Samper-Ots, M P; López-Guerra, J L; García-Cañibano, T; Díaz-Díaz, V; de Ingunza-Barón, L; Murcia-Mejía, M; Alcántara, P; Corona, J; Puertas, M M; Chust, M; Couselo, M L; Del Cerro, E; Moradiellos, J; Amor, S; Varela, A; Thuissard, I J; Sanz-Rosa, D; Taboada, B

2018-04-01

The role of surgery in stage IIIA-N2 non-small cell lung cancer (NSCLC) is an actively debated in oncology. To evaluate the value of surgery in this patient population, we conducted a multi-institutional retrospective study comparing neoadjuvant chemoradiotherapy or chemotherapy plus surgery (CRTS) to definitive chemoradiotherapy (dCRT). A total of 247 patients with potentially resectable stage T1-T3N2M0 NSCLC treated with either CRTS or dCRT between January 2005 and December 2014 at 15 hospitals in Spain were identified. A centralized review was performed to ensure resectability. A propensity score matched analysis was carried out to balance patient and tumor characteristics (n = 78 per group). Of the 247 patients, 118 were treated with CRTS and 129 with dCRT. In the CRTS group, 62 patients (52.5%) received neoadjuvant CRT and 56 (47.4%) neoadjuvant chemotherapy. Surgery consisted of either lobectomy (97 patients; 82.2%) or pneumonectomy (21 patients; 17.8%). In the matched samples, median overall survival (OS; 56 vs 29 months, log-rank p = .002) and progression-free survival (PFS; 46 vs 15 months, log-rank p < 0.001) were significantly higher in the CRTS group. This survival advantage for CRTS was maintained in the subset comparison between the lobectomy subgroup versus dCRT (OS: 57 vs 29 months, p < 0.001; PFS: 46 vs 15 months, p < 0.001), but not in the comparison between the pneumonectomy subgroup and dCRT. The findings reported here indicate that neoadjuvant chemotherapy or chemoradiotherapy followed by surgery (preferably lobectomy) yields better OS and PFS than definitive chemoradiotherapy in patients with resectable stage IIIA-N2 NSCLC. Copyright © 2018 Elsevier B.V. All rights reserved.

The early and long-term outcomes of completion pneumonectomy: report of 56 cases.

PubMed

Pan, Xufeng; Fu, Shijie; Shi, Jianxin; Yang, Jun; Zhao, Heng

2014-09-01

The aim of this study was to analyse the early and long-term results of completion pneumonectomy (CP). A retrospective review of consecutive patients who underwent CP in the Shanghai Chest Hospital. Fifty-six CP were performed between January 2003 and July 2013. There were 45 conventional CP (CCP) and 11 rescue CP (RCP) cases. CCP was defined as resection of the remaining lung because of the occurrence of new lesions in patients with previous lung resection. RCP was defined as resection of the remaining lung because of severe complication after primary lung surgery. The mortality and morbidity rates of CCP were 4.4 and 33.3%, respectively. For CCP, the morbidity was significantly higher in benign cases than in malignant cases (80.0 vs 27.5%, P = 0.04). The mortality and morbidity rates of RCP were 27.3 and 90.9%, respectively. For RCP, advanced age (P = 0.046) and preoperative mechanical ventilation (P = 0.03) were related to higher postoperative mortality. The overall 5-year survival rate was 80% for benign cases, whereas for lung malignancy cases, it was 30%. Survival varied (median 60.0 vs 35.0 vs 10.0 months, I vs II vs III, P < 0.01) for different TNM stages and was better for a time interval (between primary surgery and occurrence of lesion) of >2 years (median 60.0 vs 18.0 months, P < 0.01). CP was an operation with high risk, especially for RCP. Advanced age and mechanical ventilation before the operation were related to higher mortality in RCP. CCP of benign cases was related to higher postoperative risk, but with good survival. For lung malignancy, survival was better for a time interval (between primary surgery and occurrence of lesion) of >2 years. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Residual disease at the bronchial stump is positively associated with the risk of bronchoplerual fistula in patients undergoing lung cancer surgery: a meta-analysis

PubMed Central

Li, Shuangjiang; Fan, Jun; Zhou, Jian; Ren, Yutao; Shen, Cheng; Che, Guowei

2016-01-01

OBJECTIVES Residual disease at the bronchial stump (RDBS) is regarded as an important factor possibly resulting in bronchopleural fistula (BPF) after lung cancer surgery, but this has not been confirmed. We conducted this meta-analysis to evaluate the effects of RDBS on BPF formation in patients undergoing lung cancer surgery. METHODS PubMed and EMBASE databases were searched for full-text articles that met our eligibility criteria. Odds ratios (ORs) with 95% confidence interval (95% CI) served as the summarized outcomes. Q-test and I2 statistic were used to evaluate the level of heterogeneity, determining the fixed-effect model or random-effect model for quantitative synthesis. Sensitivity analysis was conducted to identify the possible origins of heterogeneity. The publication bias was assessed by Begg's test. RESULTS A total of eight retrospective observational studies were included in our meta-analysis. In overall analysis, the pooled outcomes indicated that RDBS was significantly associated with BPF formation after lung cancer surgery (OR: 3.12; 95% CI: 1.72–5.64; P < 0.001). In subgroup analysis, the pooled outcomes revealed a significantly increased risk of post-pneumonectomy BPF in patients with RDBS (OR: 2.78; 95% CI: 1.06–7.28; P = 0.037). The subgroup analysis assessing the effects of RDBS on post-lobectomy BPF was given up due to the scarcity of available data. No heterogeneity was revealed within this meta-analysis. No evidence for publication bias was detected by Begg's test. CONCLUSIONS Our meta-analysis indicates that RDBS is positively associated with the increased risk of BPF in patients undergoing lung cancer surgery. The further analysis also reveals an increased risk of post-pneumonectomy BPF in patients with RDBS. More accurate and comprehensive evidence should be collected and summarized in updated meta-analyses. PMID:26614527

Dynamic Regulation of Platelet-Derived Growth Factor Receptor α Expression in Alveolar Fibroblasts during Realveolarization

PubMed Central

Chen, Leiling; Acciani, Thomas; Le Cras, Tim; Lutzko, Carolyn

2012-01-01

Although the importance of platelet-derived growth factor receptor (PDGFR)-α signaling during normal alveogenesis is known, it is unclear whether this signaling pathway can regulate realveolarization in the adult lung. During alveolar development, PDGFR-α–expressing cells induce α smooth muscle actin (α-SMA) and differentiate to interstitial myofibroblasts. Fibroblast growth factor (FGF) signaling regulates myofibroblast differentiation during alveolarization, whereas peroxisome proliferator-activated receptor (PPAR)-γ activation antagonizes myofibroblast differentiation in lung fibrosis. Using left lung pneumonectomy, the roles of FGF and PPAR-γ signaling in differentiation of myofibroblasts from PDGFR-α–positive precursors during compensatory lung growth were assessed. FGF receptor (FGFR) signaling was inhibited by conditionally activating a soluble dominant-negative FGFR2 transgene. PPAR-γ signaling was activated by administration of rosiglitazone. Changes in α-SMA and PDGFR-α protein expression were assessed in PDGFR-α–green fluorescent protein (GFP) reporter mice using immunohistochemistry, flow cytometry, and real-time PCR. Immunohistochemistry and flow cytometry demonstrated that the cell ratio and expression levels of PDGFR-α–GFP changed dynamically during alveolar regeneration and that α-SMA expression was induced in a subset of PDGFR-α–GFP cells. Expression of a dominant-negative FGFR2 and administration of rosiglitazone inhibited induction of α-SMA in PDGFR-α–positive fibroblasts and formation of new septae. Changes in gene expression of epithelial and mesenchymal signaling molecules were assessed after left lobe pneumonectomy, and results demonstrated that inhibition of FGFR2 signaling and increase in PPAR-γ signaling altered the expression of Shh, FGF, Wnt, and Bmp4, genes that are also important for epithelial–mesenchymal crosstalk during early lung development. Our data demonstrate for the first time that a comparable epithelial–mesenchymal crosstalk regulates fibroblast phenotypes during alveolar septation. PMID:22652199

Predictors of Outcome in Modern Surgery for Lung Abscess.

PubMed

Schweigert, Michael; Solymosi, Norbert; Dubecz, Attila; John, Joseph; West, Doug; Boenisch, Paul Leonhard; Karmy-Jones, Riyad; Ospina, Carlos F Giraldo; Almeida, Ana Beatriz; Witzigmann, Helmut; Stein, Hubert J

2017-10-01

Background  Surgery for lung abscess is a challenging task. Timing and indications for surgery are not well established. Identification of predictors of outcome could help to clarify the role of surgery. Methods  Patients who underwent major thoracic surgery for infectious lung abscess were identified at six centers for general thoracic surgery in Germany, Spain, the United Kingdom, and the United States. Study period was 2000 to 2016. Results  There were 91 patients. Pulmonary sepsis (48), pleural empyema (43), persistent air leakage (25), acute renal failure (12), and respiratory failure with mechanical ventilation (25) were already preoperatively present. The mean Charlson index of comorbidity was 3.0 (median: 2.0; interquartile range: 3). Procedures were segmentectomy (18), lobectomy (58), and pneumonectomy (15). The 30-day mortality following surgery was 13/91.Preoperative sepsis (odds ratio [OR]: 13.69; 95% confidence interval [CI]: 1.86-610.53; p  < 0.01), preoperative persistent air leak (OR: 13.46, 95% CI: 3.00-85.37, p  < 0.01), respiratory failure (OR: 5.60; 95% CI: 1.41-24.84; p  < 0.01), acute renal failure (OR: 6.15 ; 95% CI: 1.24-29.56 ; p  = 0.01), and Charlson index of comorbidity ≥ 3 (OR: 7.19 ; 95% CI: 1.43-71.21 ; p  < 0.01) are associated with higher mortality, whereas age > 70 years ( p  = 0.46) and the extent of pulmonary resection (segmentectomy, lobectomy, pneumonectomy) have no significant influence on mortality. Patients with fatal outcome have significantly higher Charlson index of comorbidity ( p  < 0.01). Conclusions  Delayed referral for surgery is common. Significant predictors for fatal outcome are pulmonary sepsis, septic complications (air leak, pleural empyema), septic organ failure (respiratory, acute renal failure), and preexisting comorbidity (Charlson index of comorbidity ≥ 3). The extent of surgical resection shows no significant influence. Georg Thieme Verlag KG Stuttgart · New York.

Influence of Radiotherapy Technique and Dose on Patterns of Failure for Mesothelioma Patients After Extrapleural Pneumonectomy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Allen, Aaron M.; Den, Robert; Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA

2007-08-01

Purpose: Extrapleural pneumonectomy (EPP) is an effective treatment of malignant pleural mesothelioma. We compared the outcomes after moderate-dose hemithoracic radiotherapy (MDRT) and high-dose hemithoracic RT (HDRT) after EPP for malignant pleural mesothelioma. Methods and Materials: Between July 1994 and April 2004, 39 patients underwent EPP and adjuvant RT at Dana-Farber Cancer Institute/Brigham and Women's Hospital. Between 1994 and 2002, MDRT, including 30 Gy to the hemithorax, 40 Gy to the mediastinum, and boosts to positive margins or nodes to 54 Gy, was given, generally with concurrent chemotherapy. In 2003, HDRT to 54 Gy with a matched photon/electron technique was given,more » with sequential chemotherapy. Results: A total of 39 patients underwent RT after EPP. The median age was 59 years (range, 44-77). The histologic type was epithelial in 25 patients (64%) and mixed or sarcomatoid in 14 patients (36%). Of the 39 patients, 24 underwent MDRT and 15 (39%) HDRT. The median follow-up was 23 months (range, 6-71). The median overall survival was 19 months (95% confidence interval, 14-24). The median time to distant failure (DF) and local failure (LF) was 20 months (95% confidence interval, 14-26) and 26 months (95% confidence interval, 16-36), respectively. On univariate and multivariate analyses, only a mixed histologic type was predictive of inferior DF (p <0.006) and overall survival (p <0.004). The RT technique was not predictive of LF, DF, or overall survival. The LF rate was 50% (12 of 24) after MDRT and 27% (4 of 15) after HDRT (p = NS). Four patients who had undergone HDRT were alive and without evidence of disease at the last follow-up. Conclusions: High-dose hemithoracic RT appears to limit in-field LF compared with MDRT. However, DF remains a significant challenge, with one-half of our patients experiencing DF.« less

The Infection Returns: A Case of Pulmonary Sporotrichosis Relapse after Chemotherapy

PubMed Central

2018-01-01

Background Pulmonary sporotrichosis is a rare disease caused by a dimorphic fungus, Sporothrix schenckii. It is rarely found in association with malignancy. We present a case of pulmonary sporotrichosis recurrence after chemotherapy. Case Presentation A 44-year-old man, treated for pulmonary sporotrichosis in the past, presented with dysphagia and was found to have squamous cell carcinoma of the esophagus. After undergoing chemotherapy, extensive cavitary lesions were observed on thoracic computed tomography scan. A bronchoalveolar lavage revealed the presence of Sporothrix schenckii sensu lato. Despite treatment with itraconazole, he eventually required a left pneumonectomy for progressive destructive cavitary lesions involving the left lung. Conclusion This case highlights the importance of considering past fungal infections, albeit cured, in patients initiating immunosuppressive therapy. PMID:29559998

Diode-Pumped Laser for Lung-Sparing Surgical Treatment of Malignant Pleural Mesothelioma.

PubMed

Bölükbas, Servet; Biancosino, Christian; Redwan, Bassam; Eberlein, Michael

2017-06-01

Surgical resection represents one of the essential cornerstones in multimodal treatment of malignant pleural mesothelioma. In cases of tumor infiltration of the lung, lung-scarifying procedures such as lobectomies or pneumonectomies might be necessary to achieve macroscopic complete resection. However, this increases the morbidity of the patients because it leads to possible delay of the planned chemotherapy or radiotherapy. Innovative surgical techniques are therefore required to enable salvage of the lung parenchyma and optimization of surgical treatment. Here we report our first experience with a diode-pumped neodymium-doped yttrium aluminium garnet laser for parenchyma-sparing lung resection during surgery for malignant pleural mesothelioma. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

[Stapler and manual bronchial anastomosis--results of a consecutive trial series].

PubMed

Junginger, T; Walgenbach, S; Pichlmaier, H

1989-01-01

After lobectomy and pneumonectomy in experimental evaluations stapled bronchial closures showed the lowest incidence of inflammatory reaction and the highest strength determined by leakage pressure compared with other suture material. A total of 233 lung resections-performed at Surgical University Clinic Köln-Lindenthal and the Clinic for General and Abdominal Surgery of the Johannes-Gutenberg-Universität Mainz--were reviewed. Mechanical stapling reduced the rate of bronchopleural fistulas to 2.0% compared with 7.1% after manual suturing. In parallel, mortality related to bronchial stump leakage decreased to 0.7%. Main advantages of bronchial closure with staplers are the simplicity of their use, the speed and the uniformity of the closure. Thereby stapling devices are valuable completions in pulmonary surgery.

Intraoperative intracavitary hyperthermic chemotherapy for malignant pleural mesothelioma

PubMed Central

2017-01-01

Malignant pleural mesothelioma (MPM) is a dreadful disease with a poor prognosis. Multimodality therapy including surgical macroscopic complete resection is performed to treat operable MPM. Intraoperative intracavitary hyperthermic chemotherapy for MPM was reviewed. Appropriate papers published between 2006 and present were extracted by the PubMed advanced search by MPM (Title/Abstract), chemotherapy (Title/Abstract), and hyperthermia (All fields). Among the selected papers, those written in English, and treated more than ten MPM patients were reviewed. The intraoperative intracavitary hyperthermic chemotherapy has been performed following extrapleural pneumonectomy (EPP) or pleurectomy/decortication (P/D) for MPM. Cisplatin was mainly used for perfusion, and the morbidity and mortality was acceptable. In conclusion, the intraoperative intracavitary hyperthermic chemotherapy following EPP or P/D for MPM might enhance local control in the chest cavity. PMID:28706901

The state of the art in the technical performance of lung-sparing operations for malignant pleural mesothelioma.

PubMed

Friedberg, Joseph S

2013-01-01

Malignant pleural mesothelioma remains an incurable disease for which the role of surgery remains controversial. Though not yet clearly defined there does appear to be a subset of patients who benefit from a surgery-based multimodal treatment plan, beyond what would be expected with current nonoperative therapies. As with other pleural cancers it is probably not possible to achieve a microscopic complete resection with any operation. The goal of surgery in this setting, therefore, is to remove all visible and palpable disease - a macroscopic complete resection. There are basically two surgical approaches to achieve a macroscopic complete resection, lung-sacrificing and lung-sparing. Lung-sacrificing surgery, which likely leaves behind the least amount of microscopic disease, is accomplished as an extrapleural pneumonectomy. This is a well established and standardized operation. Lung-sparing surgery for malignant pleural mesothelioma, on the other hand, does not currently enjoy any degree of consistency. Not only are the reported variations on the operation widely disparate, but even the nomenclature to describe the operation is highly variable. Often the selection of a lung-sparing approach is reported as an intraoperative decision that hinges on the bulk of the cancer and/or the degree of extension into the pulmonary fissures. This article describes the current evolution of a lung-sparing procedure, radical pleurectomy, which has been used to achieve a macroscopic complete resection in over a hundred patients. Many of these cases involved bulky cancers, some exceeding two liters in volume, and often with extensive invasion of the pulmonary fissures. With the described technique there has not yet been an instance where conversion to extrapleural pneumonectomy would have contributed to the ability to achieve a macroscopic complete resection. Whether or not radical pleurectomy is the optimal approach for any or all patients undergoing surgery-based multimodal treatment for malignant pleural mesothelioma is not known, but the described technique does offer an operation that can serve as a consistent foundation for any surgery-based treatment strategy where achieving a macroscopic complete resection, while sparing the lung, is desired. Copyright © 2013. Published by Elsevier Inc.

Teflon haemoptysis.

PubMed

Aboudara, Matthew; Krimsky, William; Harley, Daniel

2012-03-20

Teflon-coated pledgeted sutures can be used to reinforce the bronchial anastomosis site following a pulmonary resection in order to prevent bronchopleural fistula formation. The authors describe the case of a 42-year-old woman with recurrent haemoptysis secondary to the erosion of a pledgeted suture through the distal trachea. The pledgeted suture was used to reinforce a defect in the wall of the distal trachea after a right upper lobectomy for stage 2a squamous cell carcinoma. Surgically, a completion pneumonectomy with carinal reconstruction was thought necessary to treat the haemoptysis. Given her age and potential surgical morbidities, the decision was made to perform serial bronchoscopies with careful pruning and eventual removal of the pledget by using the cryoprobe and a flexible scissors. This resulted in the eventual removal of the suture. Follow-up bronchoscopy 4 weeks postremoval demonstrated no residual defect on the airway wall.

Teflon haemoptysis

PubMed Central

Aboudara, Matthew; Krimsky, William; Harley, Daniel

2012-01-01

Teflon-coated pledgeted sutures can be used to reinforce the bronchial anastomosis site following a pulmonary resection in order to prevent bronchopleural fistula formation. The authors describe the case of a 42-year-old woman with recurrent haemoptysis secondary to the erosion of a pledgeted suture through the distal trachea. The pledgeted suture was used to reinforce a defect in the wall of the distal trachea after a right upper lobectomy for stage 2a squamous cell carcinoma. Surgically, a completion pneumonectomy with carinal reconstruction was thought necessary to treat the haemoptysis. Given her age and potential surgical morbidities, the decision was made to perform serial bronchoscopies with careful pruning and eventual removal of the pledget by using the cryoprobe and a flexible scissors. This resulted in the eventual removal of the suture. Follow-up bronchoscopy 4 weeks postremoval demonstrated no residual defect on the airway wall. PMID:22605709

Malignant Pleural Mesothelioma

PubMed Central

Tsao, Anne S.; Wistuba, Ignacio; Roth, Jack A.; Kindler, Hedy Lee

2009-01-01

Malignant pleural mesothelioma (MPM) is a deadly disease that occurs in 2,000 to 3,000 people each year in the United States. Although MPM is an extremely difficult disease to treat, with the median overall survival ranging between 9 and 17 months regardless of stage, there has been significant progress over the last few years that has reshaped the clinical landscape. This article will provide a comprehensive discussion of the latest developments in the treatment of MPM. We will provide an update of the major clinical trials that impact mesothelioma treatment in the resectable and unresectable settings, discuss the impact of novel therapeutics, and provide perspective on where the clinical research in mesothelioma is moving. In addition, there are controversial issues, such as the role of extrapleural pneumonectomy, adjuvant radiotherapy, and use of intensity-modulated radiotherapy versus hemithoracic therapy that will also be addressed in this manuscript. PMID:19255316

Feasibility of using high-speed electron beam x-ray CT (EBCT) to follow the time course of the pulmonary response to pneumonectomy in rabbits

NASA Astrophysics Data System (ADS)

Olson, L. E.; Wright, V. P.; Hoffman, Eric A.

1994-05-01

This report focuses on preliminary experiments designed to determine regional blood flows and air, blood, and tissue contents at end expiratory lung volume in anesthetized, paralyzed, normal, sham-operated, and pneumonectomized (left lung removed) rabbits with and without wax plombage. High temporal resolution measurements were made with an EBCT scanner during the mechanical injection of a bolus of radiopaque contrast material into the pulmonary vasculature. The time-intensity curves of selected lung regions were analyzed with VIDAR using a modification of the myocardial blood flow model proposed by Wolfkiel et al. The resulting data provided an estimate of regional blood flow and total and regional air, blood and `tissue' contents, where `tissue' represents intracellular and interstitial water, i.e., lung water exclusive of blood. The estimates of mean lung air, blood and tissue contents were similar across groups and consistent with anticipated results.

Preceding bronchial cutting for exposure of the pulmonary artery buried in scar tissue after chemoradiotherapy.

PubMed

Nomori, Hiroaki; Cong, Yue; Sugimura, Hiroshi

2017-01-01

It is often difficult to expose the pulmonary artery buried in a scar tissue, especially in lung cancer patients that responded well to neoadjuvant chemoradiotherapy. Difficulty to access pulmonary artery branches may lead to potentially unnecessary pneumonectomy. To complete lobectomy in such cases, a technique with preceding bronchial cutting for exposure of the pulmonary artery is presented. After dissecting the pulmonary vein, the lobar bronchus is cut from the opposite side of the pulmonary artery with scissors. The back wall of the lobar bronchus is cut using a surgical knife from the luminal face, which can expose the pulmonary artery behind the bronchial stump and then complete lobectomy. Fourteen patients have been treated using the present technique, enabling complete resection by lobectomy (including sleeve lobectomy in 3 patients) without major bleeding. The present procedure can expose pulmonary artery buried in scar tissue, resulting in making the lobectomy safer.

Abscess of residual lobe after pulmonary resection for lung cancer.

PubMed

Ligabue, Tommaso; Voltolini, Luca; Ghiribelli, Claudia; Luzzi, Luca; Rapicetta, Cristian; Gotti, Giuseppe

2008-04-01

Abscess of the residual lobe after lobectomy is a rare but potentially lethal complication. Between January 1975 and December 2006, 1,460 patients underwent elective pulmonary lobectomy for non-small-cell lung cancer at our institution. Abscess of the residual lung parenchyma occurred in 5 (0.3%) cases (4 bilobectomies and 1 lobectomy). Postoperative chest radiography showed incomplete expansion and consolidation of residual lung parenchyma. Flexible bronchoscopy revealed persistent bronchial occlusion from purulent secretions and/or bronchial collapse. Computed tomography in 3 patients demonstrated lung abscess foci. Surgical treatment included completion right pneumonectomy in 3 patients and a middle lobectomy in one. Complications after repeat thoracotomy comprised contralateral pneumonia and sepsis in 1 patient. Residual lobar abscess after lobectomy should be suspected in patients presenting with fever, leukocytosis, bronchial obstruction and lung consolidation despite antibiotic therapy, physiotherapy and bronchoscopy. Computed tomography is mandatory for early diagnosis. Surgical resection of the affected lobe is recommended.

In lung cancer patients where a malignant pleural effusion is found at operation could resection ever still be justified?

PubMed

Fiorelli, Alfonso; Santini, Mario

2013-08-01

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether surgery could ever be justified in non-small cell lung cancer patients with an unexpected malignant pleural effusion at surgery. Eight papers were chosen to answer the question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. Study limitations included a lack of retrospective studies, the heterogeneous patient population and various treatments applied. Three papers found that surgery--compared to exploratory thoracotomy--was associated with a survival advantage in cases of minimal pleural disease. One paper showed that the median survival time of 58.8 months in patients with pleural effusion was better than that of patients with more extensive pleural dissemination as pleural nodule (10 months; P=0.0001) or pleural nodule with effusion (19.3 months; P=0.019). Another study showed that pleural effusion patients with N0-1 status had a median survival time more than 5 years longer than patients with similar or more extensive pleural dissemination but with N2-N3 status. A further study showed a better 5-year survival time in patients with pleural effusion, than in patients with pleural nodule (22.9% vs 8.9%, respectively; P=0.45). In two papers, surgery vs exploratory thoracotomy had better survival in cases of N0 status and of complete tumour resection independently of pleural dissemination. Different strategies were employed to obtain freedom from macroscopic residual tumour, including pneumonectomy, lobar resection or, to a lesser extent, pleurectomy in patients having pleural dissemination. Only one paper reported a worse median survival time after pneumonectomy than for more limited resections (12.8 vs 24.1 months, respectively; P=0.0018). In the remaining papers, no comparison between the different resections was made. In all studies except one, surgery was a component of multimodal treatment. Intrapleural chemotherapy was largely applied with systemic adjuvant chemotherapy and/or radiotherapy. The study period and/or year of publication of most papers was 10 years or more, this may explain the different chemotherapy regimens used in the various studies. No current guidelines support surgery over conservative therapy and the identified studies in this review are not strong enough to change this recommendation.

Normal reference values for regional pulmonary peripheral airspace epithelial permeability. Influence of pneumonectomy and the smoking habit.

PubMed

Todisco, T; Dottorini, M; Rossi, F; Baldoncini, A; Palumbo, R

1989-01-01

Peripheral airspace epithelial permeability (PAEP) to diethylentriaminopentacetate (DTPA), an index of pulmonary integrity, was measured in 3 groups of subjects for different purposes: (1) to establish vertical regional reference values; (2) to determine the physiological role of acute doubling of total pulmonary blood flow; (3) to quantify the pulmonary epithelial damage in smokers and the possibility of lung protection by an agent stimulating surfactant production. This study broadens previous knowledge of PAEP. First of all, regional reference values are given for young normal nonsmoking subjects and the existence of a vertical gradient of PAEP is confirmed. Furthermore, this study shows that this gradient is independent of the vertical blood flow gradient, since an acute increase of total blood flow in pneumonectomized patients does not modify the regional distribution of PAEP. Finally, it is confirmed that the cigarette smoker's lung is more permeable than the controls and that probably a drug-stimulating surfactant production gives some protection against damage due to chronic smoking.

Penetrating cardiothoracic war wounds.

PubMed

Biocina, B; Sutlić, Z; Husedzinović, I; Rudez, I; Ugljen, R; Letica, D; Slobodnjak, Z; Karadza, J; Brida, V; Vladović-Relja, T; Jelić, I

1997-03-01

Penetrating cardiothoracic war wounds are very common among war casualties. Those injuries require prompt and specific treatment in an aim to decrease mortality and late morbidity. There are a few controversies about the best modality of treatment for such injuries, and there are not many large series of such patients in recent literature. We analysed a group of 259 patients with penetrating cardiothoracic war wounds admitted to our institutions between May 1991 and October 1992. There were 235 (90.7%) patients with thoracic wounds, 14 (5.4%) patients with cardiac, wounds and in 10 (3.7%) patients both heart and lungs were injured. The cause of injury was shrapnel in 174 patients (67%), bullets in 25 patients (9.7%), cluster bomb particles in 45 patients (17.3%) and other (blast etc.) in 15 patients (6%). Patients, 69, had concomitant injuries of various organs. The initial treatment in 164 operated patients was chest drainage in 76 (46.3%) patients, thoracotomy and suture of the lung in 71 (43.2%) patients, lobectomy in 12 (7.3%) patients and pneumonectomy in 5 (3%) patients. Complications include pleural empyema and/or lung abscess in 20 patients (8.4%), incomplete reexpansion of the lung in 10 patients (4.2%), osteomyelitis of the rib in 5 patients (2.1%) and bronchopleural fistula in 1 patient (0.4%). Secondary procedures were decortication in 12 patients, rib resection in 5 patients, lobectomy in 2 patients, pneumonectomy in 4 patients, reconstruction of the chest wall in 2 patients and closure of the bronchopleural fistula in 1 patient. The cardiac chamber involved was right ventricle in 12 patients, left ventricular in 6 patients, right atrium in 7 patients, left atrium in 3 patients, ascending aorta in 2 patients and 1 patient which involved descending aorta, right ventricle and coronary artery (left anterior descending) and inferior vena cava, respectively. The primary procedure was suture in 17 patients (in 10 patients with the additional suture of the lung), suture + extraction of the foreign body in 4 patients, 2 of them with cardiopulmonary bypass. Complications were pericardial effusion in 6 patients, arrhythmia in 2 patients, myocardial infraction in 1 patient and migration of the foreign body in 1 patient. Patients, 7, died, five of the group with concomitant injuries, two of thoracic and one of cardiac injuries (5, 1.2 and 4.2%, respectively). Penetrating cardiothoracic wounds are among the most serious injuries in war, either in combat or among civilians. In spite of their nature, they can be treated successfully with relatively low mortality and morbidity.

[Gas tamponade following intraoperative pneumothorax on a single lung: A case study].

PubMed

El Jaouhari, S D; Mamane Nassirou, O; Meziane, M; Bensghir, M; Haimeur, C

2017-04-01

Intraoperative pneumothorax is a rare complication with a high risk of cardiorespiratory arrest by gas tamponade especially on a single lung. We report the case of a female patient aged 53 years who benefited from a left pneumonectomy on pulmonary tuberculosis sequelae. The patient presented early postoperative anemia with a left hemothorax requiring an emergency thoracotomy. In perioperative, the patient had a gas tamponade following a pneumothorax of the remaining lung, and the fate has been avoided by an exsufflation. Intraoperative pneumothorax can occur due to lesions of the tracheobronchial airway, of the brachial plexus, the placement of a central venous catheter or barotrauma. The diagnosis of pneumothorax during unipulmonary ventilation is posed by the sudden onset of hypoxia associated with increased airway pressures and hypercapnia. The immediate life-saving procedure involves fine needle exsufflation before the placement of a chest tube. Prevention involves reducing the risk of barotrauma by infusing patients with low flow volumes and the proper use of positive airway pressure, knowing that despite protective ventilation, barotraumas risk still exists. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Buoyancy disorders in pet axolotls Ambystoma mexicanum: three cases.

PubMed

Takami, Yoshinori; Une, Yumi

2018-01-31

As far as we are aware, there are no previous reports on the pathologic conditions of buoyancy disorders in Ambystoma mexicanum. Herein, we describe various clinical test results, clinical outcomes, and the pathological findings of an experimental pneumonectomy procedure in 3 A. mexicanum exhibiting abnormal buoyancy. The 3 pet A. mexicanum were adults, and their respective ages and body weights were 1, 5, and 6 yr and 48, 55, and 56 g. Two of these cases were confirmed via radiographic examination to have free air within the body cavity, and all 3 cases were found via ultrasonography to have an acoustic shadow within the body cavity and were diagnosed with pneumocoelom. Lung perforations were detected macroscopically in 2 of the cases, and all 3 cases had fibrosis in the caudal ends of the lungs. Removal of the lung lesions eliminated the abnormal buoyancy in all 3 cases. We concluded that air had leaked into the body cavity from the lungs, and we propose that lung lesions are an important cause of buoyancy disorders in A. mexicanum.

Well-differentiated papillary mesothelioma with invasion to the chest wall.

PubMed

Torii, Ikuko; Hashimoto, Masaki; Terada, Takayuki; Kondo, Nobuyuki; Fushimi, Hiroaki; Shimazu, Kohki; Takeda, Shin-Ichi; Takuwa, Teruhisa; Okumura, Yoshitomo; Sato, Ayuko; Yamamoto, Tadashi; Fukuoka, Kazuya; Tanaka, Fumihiro; Nishigami, Takashi; Nakano, Takashi; Hasegawa, Seiki; Tsujimura, Tohru

2010-02-01

Well-differentiated papillary mesothelioma (WDPM) is an uncommon tumor with a papillary architecture, bland cytologic features, a tendency toward superficial spread without invasion, and good prognosis with prolonged survival. WDPM occurs primarily in the peritoneum of women, but also rarely in the pleura. We here report a case of 48-year-old woman who developed WDPM in the pleura with no history of asbestos exposure. Tumors were multifocal and widespread with a velvety appearance on the surface of parietal and visceral pleurae resected by extrapleural pneumonectomy (EPP). Tumors showed papillary structures with fibrovascular cores and lined by epithelioid cells. Immunohistochemically, these epithelioid tumor cells were positive for epithelial membrane antigen (EMA), a marker of malignant mesothelioma, with more than 50% positive for p53. Tumor cells microinvaded into subpleural parenchyma of the lung and minimally spread to adipose tissues of the mediastinal lesion. In addition, tumor cells invaded into the chest wall with a trabecular or glandular architecture. Based on these findings, this case is pathologically considered as WDPM of the pleura with malignant potential. Copyright 2009 Elsevier Ireland Ltd. All rights reserved.

Videothoracoscopy and muscle flaps in the treatment of bronchial stump fistula.

PubMed

Kowalewski, J; Brocki, M; Galikowski, M; Kapron, K

1999-01-01

The aim of the paper is to report our surgical technique applied for treatment of broncho-pleural fistula (BPF) as well as the results of the treatment. From 1992 to 1998 we performed 127 pneumonectomies for lung cancer. In 5 cases (3.9%) bronchial stump insufficiency developed postoperatively. Three patients were treated by means of videothoracoscopy (the Multifire Endo Hernia Stapler was used to clipped the fistula). Rethoracotomy with myoplasty was performed four times in 3 patients. In one patient both the methods were employed. In 2 out of 3 cases videothoracoscopic treatment was successful and the patients were discharged without signs of BPF and pleural empyema. In one case the recurrence of the fistula occurred and the stump of the bronchus was successfully covered with the pectoral musce flap 3 days later. In two cases after rethoracotomy and myoplasty (one of them was reoperated twice) the recurrence of BPF occurred and both the patients died due to cardiopulmonary failure. Despite the limited experience, we think videothoracoscopy is worth considering as a tool for treatment of BPF.

[Changes in cardiopulmonary functional reserve after thoracic surgery assessed by treadmill exercise test].

PubMed

Matsubara, M; Tsubota, N

1991-07-01

The authors evaluated the effect of thoracic surgery on cardiopulmonary functional reserve using a three-minute incremental test on treadmill before and after operation in 148 patients undergoing thoracic surgery. Patients were divided into two groups according to the presence or absence of respiratory symptoms during the exercise test. In all patients, the number of cases with hypoxemia induced by exercise test increased postoperatively including all cases with pneumonectomy. The number of patients who halted the test because of respiratory symptoms (Group A) increased after operation (45 cases before (30.4%), 82 cases after (55.4%)). Most of them showed at least 10 Torr lower PaO2 levels than their basal levels during exercise. Before operation, patients in Group A (n = 45) showed significantly lower FEV1.0% than those who halted the test because of other symptoms (Group B, n = 103) (68.0 +/- 12.5% vs 76.0 +/- 9.7%, mean +/- S.E. p less than 0.05, Student's t-test). After operation, patients in Group A (n = 82) showed a significantly lower %DLco than those in Group B (n = 66) (71.4 +/- 14.3% vs 88.6 +/- 16.8%, p less than 0.05). Preoperative %DLco did not differ between the two groups. Consequently, postoperative decrease in %DLco was characteristic for patients with respiratory symptoms, suggesting that hypoxemia during exercise induced by reduction in diffusion capacity may be responsible for their respiratory symptoms. The anaerobic threshold (AT), and index of aerobic capacity, and symptomlimited maximal oxygen consumption (VO2 max (s.l)), VO2 at the end of exercise, fell to 78.4% and 79.1% of preoperative levels respectively one month after operation. Both indices recovered to 85% of preoperative levels at six months after operation. AT and VO2 max (s.l) values were expressed as a percent of predicted maximal VO2 values for age, body weight and sex (%AT, %VO2 (s.l)). The %VO2 max (s.l) was significantly lower in patients with pneumonectomy (n = 8) as compared with that in patients with lobectomy (n = 55) (51.1 +/- 6.4% vs 60.6 +/- 11.4%, p less than 0.05). Patients with thoracotomy (n = 35) only showed significantly higher %VO2 max (s.l) values (70.5 +/- 12.1%) than those of patients with lobectomy (p less than 0.05). The %AT did not show significant differences among different operative procedure groups. Despite a good preoperative correlation (r = 0.725) between %VO2 max (s.l) and %AT in all patients, there was no correlation between the indices postoperatively.(ABSTRACT TRUNCATED AT 400 WORDS)

Non-intubated video-assisted thoracic surgery management of secondary spontaneous pneumothorax

PubMed Central

Bolufer, Sergio; Navarro-Martinez, Jose; Lirio, Francisco; Corcoles, Juan Manuel; Rodriguez-Paniagua, Jose Manuel

2015-01-01

Secondary spontaneous pneumothorax (SSP) is serious entity, usually due to underlying disease, mainly chronic obstructive pulmonary disease (COPD). Its morbidity and mortality is high due to the pulmonary compromised status of these patients, and the recurrence rate is almost 50%, increasing mortality with each episode. For persistent or recurrent SSP, surgery under general anesthesia (GA) and mechanical ventilation (MV) with lung isolation is the gold standard, but ventilator-induced damages and dependency, and postoperative pulmonary complications are frequent. In the last two decades, several groups have reported successful results with non-intubated video-assisted thoracic surgery (NI-VATS) with thoracic epidural anesthesia (TEA) and/or local anesthesia under spontaneous breathing. Main benefits reported are operative time, operation room time and hospital stay reduction, and postoperative respiratory complications decrease when comparing to GA, thus encouraging for further research in these moderate to high risk patients many times rejected for the standard regimen. There are also reports of special situations with satisfactory results, as in contralateral pneumonectomy and lung transplantation. The aim of this review is to collect, analyze and discuss all the available evidence, and seek for future lines of investigation. PMID:26046045

Non-intubated video-assisted thoracic surgery management of secondary spontaneous pneumothorax.

PubMed

Galvez, Carlos; Bolufer, Sergio; Navarro-Martinez, Jose; Lirio, Francisco; Corcoles, Juan Manuel; Rodriguez-Paniagua, Jose Manuel

2015-05-01

Secondary spontaneous pneumothorax (SSP) is serious entity, usually due to underlying disease, mainly chronic obstructive pulmonary disease (COPD). Its morbidity and mortality is high due to the pulmonary compromised status of these patients, and the recurrence rate is almost 50%, increasing mortality with each episode. For persistent or recurrent SSP, surgery under general anesthesia (GA) and mechanical ventilation (MV) with lung isolation is the gold standard, but ventilator-induced damages and dependency, and postoperative pulmonary complications are frequent. In the last two decades, several groups have reported successful results with non-intubated video-assisted thoracic surgery (NI-VATS) with thoracic epidural anesthesia (TEA) and/or local anesthesia under spontaneous breathing. Main benefits reported are operative time, operation room time and hospital stay reduction, and postoperative respiratory complications decrease when comparing to GA, thus encouraging for further research in these moderate to high risk patients many times rejected for the standard regimen. There are also reports of special situations with satisfactory results, as in contralateral pneumonectomy and lung transplantation. The aim of this review is to collect, analyze and discuss all the available evidence, and seek for future lines of investigation.

Customized Hinged Covered Metallic Stents for the Treatment of Benign Main Bronchial Stenosis.

PubMed

Han, Xinwei; Al-Tariq, Quazi; Zhao, Yanle; Li, Lei; Cheng, Zhe; Wang, Huaqi; Liu, Chao; Jiao, Dechao; Wu, Gang

2017-08-01

To address the limitations of silicone stents, we designed a hinged self-expandable covered metallic stent. The aim of this study was to evaluate the safety and efficacy of the customized stents in clinical applications. This was a retrospective analysis. Under conscious sedation and local anesthesia, the stents were implanted or removed by interventional radiologists, with fluoroscopic guidance. Of 24 patients with benign main bronchial stenosis, stents were successfully placed in 21 (87.5%). The low-pressure balloon before dilation failed in 1 case (4.17%) of left main bronchial cicatricial stenosis. In 2 other cases (8.33%), stent placement was abandoned. Stents were successfully removed between 29 and 103 days after the procedure. After stent removal, the follow-up lasted for at least 12 months. Restenosis occurred only in 1 case (4.55%) owing to bronchial collapse 3 days after stent removal. Dyspnea occurred in another case (4.55%) at 2 months after retrieval; recurrence was confirmed using bronchoscopy, leading to a left pneumonectomy. The described procedure is safe and easy to be performed and avoids the use of intubation, bronchoscopy, and general anesthesia. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

A Case of Solitary Well-Differentiated Papillary Mesothelioma with Invasive Foci in the Pleura.

PubMed

Shimizu, Shigeki; Yoon, Hyung-Eun; Ito, Norimasa; Tsuji, Taisuke; Funakoshi, Yasunobu; Utsumi, Tomoki; Sakaguchi, Masahiro; Tsujimura, Toru; Kasai, Takahiko; Hiroshima, Kenzo; Matsumura, Akihide

2017-01-01

Well-differentiated papillary mesothelioma (WDPM) is a rare, distinct tumor consisting of mesothelial cells with a papillary architecture, bland cytological features, and a tendency toward superficial spread without invasion. Rare cases with superficial invasion are termed WDPM with invasive foci. We report a case of solitary WDPM with invasive foci in the pleura. A 61-year-old woman presented with a lung adenocarcinoma. A small papillary lesion measuring 29 × 10 × 8 mm was incidentally found in the parietal pleura during a lobectomy for the lung adenocarcinoma. The fibrovascular core of the small papillary lesion was surrounded by a single layer of cuboidal cells with mild to moderate atypia and large nucleoli. Atypical mesothelial cells focally invaded the submesothelial layer. The cells of the papillary lesion were positive for cytokeratins and mesothelial markers. The Ki67 index was <1 %. The lesion did not show p16 loss on fluorescence in situ hybridization. We could not detect atypical mesothelial cells in the specimen from an extrapleural pneumonectomy. WDPM with invasive foci is prone to multifocality; however, our case represents a solitary case in the pleura. © 2016 Japanese Society of Pathology and John Wiley & Sons Australia, Ltd.

Lung cancer, brucellosis and tuberculosis: remarkable togetherness

PubMed Central

Akkoyunlu, Muhammed Emin; Akkoyunlu, Yasemin; Hakyemez, Ismail Necati; Erboy, Fatma; Arvas, Gulhan; Aslan, Turan

2013-01-01

A 68 years old male farmer referred with cough, expectorating sputum, intermittant fever, night sweats, fatigue and anorexia persisting for two weeks. There was a history of 80 packs each year of smoking and he was still an active smoker. Pneumonectomy was performed because of pulmonary epidermoid cancer and he received chemotherapy. He was diagnosed lung tuberculosis and using anti-tuberculous treatment for 4 months. He had a weight loss of 8 kg in last month. His body tempereature was 38.5 °C. Heart rate was 100/min. ESR was 51mm/h and CRP was 5.6 mg/dL. There was no proliferation in blood and sputum cultures. Three sputum specimens were examined and AFB wasn't detected. Fibronodular infiltration was seen in right lower zone of chest X-ray. In thorax CT, fibronodular densities were seen in lower lobe anterior and posterior segments. Brucella melitensis was isolated in blood culture. Second bronchoscopy was performed with suspect of brucellosis pneumonia. Brucella tube agglutination test was positive at titer 1/320 in the bronchial lavage fluid and 1/640 in concurrent serum sample. In cases with chronic cough or pneumonia which is irresponsive to nonspecific antibiotherapy, respiratory brucellosis must be rememberred in endemic areas.

[Role of pulmonary resections in management of multidrug-resistant tuberculosis. A monocentric series of 29 patients].

PubMed

Bouchikh, M; Achir, A; Caidi, M; El Aziz, S; Benosman, A

2013-12-01

Multidrug-resistant tuberculosis (MDR-TB) is a worldwide health problem. Surgery is often used as an adjuvent therapy with anti-tuberculosis agents. The aim of this study is to present our results of pulmonary resections in the treatment of MDR-TB. [corrected] This is a retrospective monocentric study of 29 patients operated on between 1995 and 2010 for MDR-TB. Tuberculosis was evolving from 9 to 108 months with a median of 34.77±19.88 months. The average number of tuberculosis relapses was 2.73 per patient. All patients had a destroyed and/or cavitary parenchyma and 17 had bacilli in sputum at the time of surgery. Lobectomy (51.17%) and pneumonectomy (41.37%) were the main interventions carried out. The operative mortality was 3.44%. Complications such prolonged air leaking and empyema had occurred in 9 patients. The rate of postoperative microbiological conversion was 88.23%. One patient had a relapse 5 months after surgery. Surgery associated with medical treatment provides a high cure rate to the detriment of an acceptable morbidity and mortality. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

Surgery for malignant pleural mesothelioma: an international guidelines review

PubMed Central

Cardillo, Giuseppe; Zirafa, Carmelina Cristina; Carleo, Francesco; Facciolo, Francesco; Fontanini, Gabriella; Mutti, Luciano; Melfi, Franca

2018-01-01

Currently there is no universally accepted surgical therapy for malignant pleural mesothelioma (MPM). The goal of surgery in this dismal disease is a macroscopic complete resection (MCR) and there are two types of intervention with a curative intent. At one side, there is the extrapleural pneumonectomy (EPP) which consists in an en-bloc resection of the lung, pleura, pericardium and diaphragm and at the other side, there is pleurectomy/decortication (P/D) a lung-sparing surgery. Initially, EPP was considered the only surgical option with a curative aim, but during the decades P/D have acquired a role of increasing importance in MPM therapy. Several randomized prospective trials are required to establish the best strategy in the treatment of pleural mesothelioma. Although which is the best surgical option remains unclear, the International Mesothelioma Interest Group (IMIG), recently have stated that the type of surgery depends on clinical factors and on individual surgical judgment and expertise. Moreover, according to the current evidence, the surgery should be performed in high-volume centres within multimodality protocols. The aim of this study is to examine the currently available international guidelines in the surgical diagnosis and treatment of MPM. PMID:29507797

Low-Flow Extracorporeal Carbon Dioxide Removal Using the Hemolung Respiratory Dialysis System® to Facilitate Lung-Protective Mechanical Ventilation in Acute Respiratory Distress Syndrome.

PubMed

Akkanti, Bindu; Rajagopal, Keshava; Patel, Kirti P; Aravind, Sangeeta; Nunez-Centanu, Emmanuel; Hussain, Rahat; Shabari, Farshad Raissi; Hofstetter, Wayne L; Vaporciyan, Ara A; Banjac, Igor S; Kar, Biswajit; Gregoric, Igor D; Loyalka, Pranav

2017-06-01

Extracorporeal carbon dioxide removal (ECCO 2 R) permits reductions in alveolar ventilation requirements that the lungs would otherwise have to provide. This concept was applied to a case of hypercapnia refractory to high-level invasive mechanical ventilator support. We present a case of an 18-year-old man who developed post-pneumonectomy acute respiratory distress syndrome (ARDS) after resection of a mediastinal germ cell tumor involving the left lung hilum. Hypercapnia and hypoxemia persisted despite ventilator support even at traumatic levels. ECCO 2 R using a miniaturized system was instituted and provided effective carbon dioxide elimination. This facilitated establishment of lung-protective ventilator settings and lung function recovery. Extracorporeal lung support increasingly is being applied to treat ARDS. However, conventional extracorporeal membrane oxygenation (ECMO) generally involves using large cannulae capable of carrying high flow rates. A subset of patients with ARDS has mixed hypercapnia and hypoxemia despite high-level ventilator support. In the absence of profound hypoxemia, ECCO 2 R may be used to reduce ventilator support requirements to lung-protective levels, while avoiding risks associated with conventional ECMO.

Impact of Major Pulmonary Resections on Right Ventricular Function: Early Postoperative Changes.

PubMed

Elrakhawy, Hany M; Alassal, Mohamed A; Shaalan, Ayman M; Awad, Ahmed A; Sayed, Sameh; Saffan, Mohammad M

2018-01-15

Right ventricular (RV) dysfunction after pulmonary resection in the early postoperative period is documented by reduced RV ejection fraction and increased RV end-diastolic volume index. Supraventricular arrhythmia, particularly atrial fibrillation, is common after pulmonary resection. RV assessment can be done by non-invasive methods and/or invasive approaches such as right cardiac catheterization. Incorporation of a rapid response thermistor to pulmonary artery catheter permits continuous measurements of cardiac output, right ventricular ejection fraction, and right ventricular end-diastolic volume. It can also be used for right atrial and right ventricular pacing, and for measuring right-sided pressures, including pulmonary capillary wedge pressure. This study included 178 patients who underwent major pulmonary resections, 36 who underwent pneumonectomy assigned as group (I) and 142 who underwent lobectomy assigned as group (II). The study was conducted at the cardiothoracic surgery department of Benha University hospital in Egypt; patients enrolled were operated on from February 2012 to February 2016. A rapid response thermistor pulmonary artery catheter was inserted via the right internal jugular vein. Preoperatively the following was recorded: central venous pressure, mean pulmonary artery pressure, pulmonary capillary wedge pressure, cardiac output, right ventricular ejection fraction and volumes. The same parameters were collected in fixed time intervals after 3 hours, 6 hours, 12 hours, 24 hours, and 48 hours postoperatively. For group (I): There were no statistically significant changes between the preoperative and postoperative records in the central venous pressure and mean arterial pressure; there were no statistically significant changes in the preoperative and 12, 24, and 48 hour postoperative records for cardiac index; 3 and 6 hours postoperative showed significant changes. There were statistically significant changes between the preoperative and postoperative records for heart rate, mean pulmonary artery pressure, pulmonary capillary wedge pressure, pulmonary vascular resistance, right ventricular ejection fraction and right ventricular end diastolic volume index, in all postoperative records. For group (II): There were no statistically significant changes between the preoperative and all postoperative records for the central venous pressure, mean arterial pressure and cardiac index. There were statistically significant changes between the preoperative and postoperative records for heart rate, mean pulmonary artery pressure, pulmonary capillary wedge pressure, pulmonary vascular resistance, right ventricular ejection fraction and right ventricular end diastolic volume index in all postoperative records. There were statistically significant changes between the two groups in all postoperative records for heart rate, mean pulmonary artery pressure, pulmonary capillary wedge pressure, pulmonary vascular resistance, right ventricular ejection fraction and right ventricular end diastolic volume index. There is right ventricular dysfunction early after major pulmonary resection caused by increased right ventricular afterload. This dysfunction is more present in pneumonectomy than in lobectomy. Heart rate, mean pulmonary artery pressure, pulmonary capillary wedge pressure, pulmonary vascular resistance, right ventricular ejection fraction, and right ventricular end diastolic volume index are significantly affected by pulmonary resection.

[Primary pulmonary hemangiopericytoma: 2 new cases].

PubMed

Essola, B; Remmelink, M; Kessler, R; Scillia, P; Rocmans, P

2003-10-01

We describe two new resected cases of primary pulmonary hemangiopericytoma and the review of cases published in the period 1954-2002. The first patient has a large pulmonary mass of the right apex revealed by scapular pain. The right upper lobectomy with free margins reveals hemangiopericytoma. Pelvic and pulmonary metastases appear two years after surgery, treated by two series of chemotherapy without clinical response. After acute nephrotoxicity controlled by hemodialysis, the patient dies with distant metastases three years and an half after thoracotomy. The second patient develops dry cough and thoracic pain with discovery of a cavitary mass in the right pulmonary field. Fine needle aspiration cytology suggests a mesenchymatous lesion. Three months after extended pneumonectomy, the intrathoracic tumour relapses and regresses partially under chemotherapy. Femoral and brain metastases are irradiated. The patient dies 22 months after thoracotomy. Histology and immunohistochemistry of both tumours closely related to solitary fibrous tumour confirm malignant hemangiopericytoma. Primary pulmonary hemangiopericytoma is rare and may be benign or malignant. Radical resection is the best treatment. Chemotherapy and radiotherapy may improve the prognosis. Compared with lung cancer, the tumour is a slow growing mass, often voluminous, with delayed symptoms, very few lymph node dissemination, rare brain metastasis, more frequent cutaneous or retroperitoneal dissemination, often after long-term and requiring indeed a 10 to 20 years follow-up.

Video-assisted thoracic surgical procedures in children.

PubMed

Decampli, William M.

1998-01-01

The general principles and current applications of pediatric video-assisted cardiothoracic surgery (PVACTS) are reviewed. The purpose of PVACTS is to improve surgical quality and precision in selected operations. In the 1990s PVACTS has expanded to include the management of a variety of pulmonary, mediastinal, and cardiac lesions. Currently, PVACTS is carried out using a video camera connected to a low-profile scope and a specialized set of surgical instruments. PVACTS is an accepted modality for the diagnosis (by biopsy) of pleuropulmonary and mediastinal disease, and the treatment of pediatric empyema, spontaneous pneumothorax, and mediastinal cysts. Diaphragmatic plication, repair of chylous leak, and ligation of collateral vessels have all been done using PVACTS. PVACTS patent ductus arteriosus (PDA) ligation and vascular ring repair are being successfully carried out in several institutions. The technique at The Children's Hospital of Philadelphia is described. Indications and techniques for PVACTS lobectomy and pneumonectomy are less well established. Suggested anecdotal methods are described. Cardioscopy carries the hope of improving intracardiac repair, and has been applied to several lesions. The future of PVACTS depends on the surgeon's willingness to master it, industry's willingness to customize instruments for pediatric use, and developments in the fields of virtual imaging and augmented reality. Copyright 1998 by W.B. Saunders Company

Early pulmonary toxicity following lung stereotactic body radiation therapy delivered in consecutive daily fractions.

PubMed

Stauder, Michael C; Macdonald, O Kenneth; Olivier, Kenneth R; Call, Jason A; Lafata, Kyle; Mayo, Charles S; Miller, Robert C; Brown, Paul D; Bauer, Heather J; Garces, Yolanda I

2011-05-01

Identify the incidence of early pulmonary toxicity in a cohort of patients treated with lung stereotactic body radiation therapy (SBRT) on consecutive treatment days. A total of 88 lesions in 84 patients were treated with SBRT in consecutive daily fractions (Fx) for medically inoperable non-small cell lung cancer or metastasis. The incidence of pneumonitis was evaluated and graded according to the NCI CTCAE v3.0. With a median follow-up of 15.8 months (range 2.5-28.6), the median age at SBRT was 71.8 years (range 23.8-87.8). 47 lesions were centrally located and 41 were peripheral. Most central lesions were treated with 48Gy in 4 Fx, and most peripheral lesions with 54Gy in 3 Fx. The incidence of grade ≥ 2 pneumonitis was 12.5% in all patients treated, and 14.3% among the subset of patients treated with 54Gy in 3 Fx. A total of two grade 3 toxicities were seen as one grade 5 toxicity in a patient treated for recurrence after pneumonectomy. Treating both central and peripheral lung lesions with SBRT in consecutive daily fractions in this cohort was well tolerated and did not cause excessive early pulmonary toxicity. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

[The technique of sleeve resection on the bronchial and pulmonary vascular tree].

PubMed

Branscheid, D; Beshay, M

2013-06-01

Sleeve resections of the lungs have affected the oncologic radicality, parenchyma and lung function-saving resections and extended the indications for operations in thoracic surgery. Whenever lung amputations can be avoided by bronchoplastic and/or angioplastic procedures with the same radicality, sleeve resection should be performed. In centrally located distinct malignomas, intraluminal tumor growth (T3) infiltrations of peribronchial or extrabronchial areas, the lobular ostia and the pulmonary artery (T2/T3) as well as lymph node involvement (N1/N2), these procedures give a better qualitative survival and lower morbidity and mortality rates. Broncoscope-guided localization of a double lumen tube and routine anesthesia monitoring are mandatory. Before performing sleeve resections a complete lymph node dissection should be done without denuding the area of the anastomosis and sparing the bronchial arteries. Preoperative endoscopic biopsies, knowledge of the topography and mobilization of the vascular and bronchial tree, subtile operation techniques, perioperative and postoperative videobronchoscopic guidance as well as intraoperative frozen sections and a tension-free and smooth anastomosis, avoid postoperative complications. Depending on the blood supply of the bronchial tree a vascularized flap is indicated. Operability can therefore be achieved in elderly patients with limited pulmonary function, particularly those under adjuvant or neoadjuvant therapy who are no longer suitable for pneumonectomy.

Pulmonary alveolar type I cell population consists of two distinct subtypes that differ in cell fate

PubMed Central

Wang, Yanjie; Tang, Zan; Huang, Huanwei; Li, Jiao; Wang, Zheng; Yu, Yuanyuan; Zhang, Chengwei; Li, Juan; Dai, Huaping; Wang, Fengchao; Cai, Tao

2018-01-01

Pulmonary alveolar type I (AT1) cells cover more than 95% of alveolar surface and are essential for the air–blood barrier function of lungs. AT1 cells have been shown to retain developmental plasticity during alveolar regeneration. However, the development and heterogeneity of AT1 cells remain largely unknown. Here, we conducted a single-cell RNA-seq analysis to characterize postnatal AT1 cell development and identified insulin-like growth factor-binding protein 2 (Igfbp2) as a genetic marker specifically expressed in postnatal AT1 cells. The portion of AT1 cells expressing Igfbp2 increases during alveologenesis and in post pneumonectomy (PNX) newly formed alveoli. We found that the adult AT1 cell population contains both Hopx+Igfbp2+ and Hopx+Igfbp2− AT1 cells, which have distinct cell fates during alveolar regeneration. Using an Igfbp2-CreER mouse model, we demonstrate that Hopx+Igfbp2+ AT1 cells represent terminally differentiated AT1 cells that are not able to transdifferentiate into AT2 cells during post-PNX alveolar regeneration. Our study provides tools and insights that will guide future investigations into the molecular and cellular mechanism or mechanisms underlying AT1 cell fate during lung development and regeneration. PMID:29463737

Value of flexible bronchoscopy in the pre-operative work-up of solitary pulmonary nodules.

PubMed

Schwarz, Carsten; Schönfeld, Nicolas; Bittner, Roland C; Mairinger, Thomas; Rüssmann, Holger; Bauer, Torsten T; Kaiser, Dirk; Loddenkemper, Robert

2013-01-01

The diagnostic value of flexible bronchoscopy in the pre-operative work-up of solitary pulmonary nodules (SPN) is still under debate among pneumologists, radiologists and thoracic surgeons. In a prospective observational manner, flexible bronchoscopy was routinely performed in 225 patients with SPN of unknown origin. Of the 225 patients, 80.5% had lung cancer, 7.6% had metastasis of an extrapulmonary primary tumour and 12% had benign aetiology. Unsuspected endobronchial involvement was found in 4.4% of all 225 patients (or in 5.5% of patients with lung cancer). In addition, flexible bronchoscopy clarified the underlying aetiology in 41% of the cases. The bronchoscopic biopsy results from the SPN were positive in 84 (46.5%) patients with lung cancer. Surgery was cancelled due to the results of flexible bronchoscopy in four cases (involvement of the right main bronchus (impaired pulmonary function did not allow pneumonectomy) n=1, small cell lung cancer n=1, bacterial pneumonia n=2), and the surgical strategy had to be modified to bilobectomy in one patient. Flexible bronchoscopy changed the planned surgical approach in five cases substantially. These results suggest that routine flexible bronchoscopy should be included in the regular pre-operative work-up of patients with SPN.

Prevention of infection in war chest injuries.

PubMed Central

Romanoff, H

1975-01-01

Infection is a major complication of military chest injuries. In a series of 142 wounded, infectious complications occurred in 7 (4.9%). Factors influencing the incidence of infection are evaluated. In this group of injuries, 81 patients were admitted soon after wounding. The intrathoracic damage was severe, due to penetration of metallic fragment. The hemothorax was treated by immediate intercostal drainage. Immediate thoracotomy was performed in 10 patients and late thoractomy in 15. One patient developed a lung abscess and 5 patients had infection following thoracotomy (7.4%). Another 61 wounded patients had been first managed in a forward hospital, including three with thoractomy for massive bleeding. Two, not in a forward hospital, had a bullet removed from the lung. Upon admission to this hospital, intercostal drains were inserted when needed and four patients underwent thoracotomy. Larger wounds were debrided in 24 patients. Late thoracotomy was perfromed in seven. Chronic empyema developed in one patient after pneumonectomy performed at the field hospital, resulting in a resuscitation or infection rate of less than 2%. Factors contributing to a low infection rate were: early drainage of hemothoraces and wide debridement of larger wounds with delayed closure and avoidance of thoracotomy as primary treatment. Resection of lung tissue was avoided. Thoraco-abdominal injuries were treated separately. The clotted hemothorax was immediately evacuated. Prolonged antibiotic therapy was usually indicated. PMID:1211991

Failure Rates and Patterns of Recurrence in Patients With Resected N1 Non-Small-Cell Lung Cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Varlotto, John M., E-mail: jvarlotto@hmc.psu.edu; Medford-Davis, Laura Nyshel; Recht, Abram

2011-10-01

Purpose: To examine the local and distant recurrence rates and patterns of failure in patients undergoing potentially curative resection of N1 non-small-cell lung cancer. Methods and Materials: The study included 60 consecutive unirradiated patients treated from 2000 to 2006. Median follow-up was 30 months. Failure rates were calculated by the Kaplan-Meier method. A univariate Cox proportional hazard model was used to assess factors associated with recurrence. Results: Local and distant failure rates (as the first site of failure) at 2, 3, and 5 years were 33%, 33%, and 46%; and 26%, 26%, and 32%, respectively. The most common site ofmore » local failure was in the mediastinum; 12 of 18 local recurrences would have been included within proposed postoperative radiotherapy fields. Patients who received chemotherapy were found to be at increased risk of local failure, whereas those who underwent pneumonectomy or who had more positive nodes had significantly increased risks of distant failure. Conclusions: Patients with resected non-small-cell lung cancer who have N1 disease are at substantial risk of local recurrence as the first site of relapse, which is greater than the risk of distant failure. The role of postoperative radiotherapy in such patients should be revisited in the era of adjuvant chemotherapy.« less

Correlation of clinicopathologic features and lung squamous cell carcinoma subtypes according to the 2015 WHO classification.

PubMed

Chen, Rongrong; Ding, Zhengping; Zhu, Lei; Lu, Shun; Yu, Yongfeng

2017-12-01

This study aimed to determine the relationship between clinicopathologic features and lung squamous cell carcinoma (LSCC) subtypes according to the 2015 WHO classification. We identified 824 operable LSCC patients undergoing a complete surgical resection at Shanghai Chest Hospital between April 2015 and January 2017. Immunohistochemistry was used to investigate the clinicopathologic features. Among them, the percentages of LSCC subtypes were 66.1% (545/824), 28.6% (236/824), and 5.2% (43/824) for keratinizing squamous cell carcinoma (KSCC), nonkeratinizing squamous cell carcinoma (NKSCC), and basaloid squamous cell carcinoma (BSCC), respectively. There were more males, more smokers, and more pneumonectomy surgeries in KSCC patients (p = 0.008, p = 0.000, p = 0.043). There were more N2 lymph node involvement and pathological stage III in NKSCC patients (p = 0.01, p = 0.03). BSCC did not demonstrate specificity to anything, but expressed adenocarcinoma markers more frequently. No significant difference existed between pathological subtypes and other clinicopathologic features, such as age, location type, visceral pleural involvement and lymphovascular invasion. The frequencies of EGFR sensitive mutations and ALK rearrangements were not significantly different among three subtypes. Significant relationships exist between some clinicopathologic features and LSCC subtypes. Copyright © 2017 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

Baicalein Ameliorates Pulmonary Arterial Hypertension Caused by Monocrotaline through Downregulation of ET-1 and ETAR in Pneumonectomized Rats.

PubMed

Hsu, Wen-Lin; Lin, Yu-Chieh; Jeng, Jing-Ren; Chang, Heng-Yuan; Chou, Tz-Chong

2018-05-08

Baicalein (BE) extracted from Scutellaria baicalensis Georgi is able to alleviate various cardiovascular and inflammatory diseases. However, the effects of BE on pulmonary arterial hypertension (PAH) remain unknown. Therefore, the present study aimed to examine whether BE ameliorates pneumonectomy and monocrotaline-induced PAH in rats and further investigate the underlying molecular mechanisms. Administration of BE greatly attenuated the development of PAH as evidenced by an improvement of its characteristic features, including elevation of right ventricular systolic pressure, right ventricular hypertrophy, and pulmonary vascular remodeling. Moreover, the increased protein expression of endothelin-1 (ET-1) and ET A receptor (ET A R), superoxide overproduction, and activation of Akt/ERK1/2/GSK3[Formula: see text]/[Formula: see text]-catenin pathway that occurred in the lungs of PAH rats were markedly reversed by BE treatment. Compared with the untreated PAH rats, higher expression of endothelial nitric oxide synthase (eNOS), but lower levels of inducible nitric oxide synthase and vWF were observed in BE-treated PAH rats. Collectively, treatment with BE remarkably attenuates the pathogenesis of PAH, and the protection of BE may be associated with suppressing Akt/Erk1/2/GSK3[Formula: see text]/[Formula: see text]-catenin/ET-1/ET A R signaling and preventing endothelial dysfunction. These results suggest that BE is a potential agent for treatment of PAH.

A randomised, controlled, double-blind trial of ultrasound-guided phrenic nerve block to prevent shoulder pain after thoracic surgery.

PubMed

Blichfeldt-Eckhardt, M R; Laursen, C B; Berg, H; Holm, J H; Hansen, L N; Ørding, H; Andersen, C; Licht, P B; Toft, P

2016-12-01

Moderate to severe ipsilateral shoulder pain is a common complaint following thoracic surgery. In this prospective, parallel-group study at Odense University Hospital, 76 patients (aged > 18 years) scheduled for lobectomy or pneumonectomy were randomised 1:1 using a computer-generated list to receive an ultrasound-guided supraclavicular phrenic nerve block with 10 ml ropivacaine or 10 ml saline (placebo) immediately following surgery. A nerve catheter was subsequently inserted and treatment continued for 3 days. The study drug was pharmaceutically pre-packed in sequentially numbered identical vials assuring that all participants, healthcare providers and data collectors were blinded. The primary outcome was the incidence of unilateral shoulder pain within the first 6 h after surgery. Pain was evaluated using a numeric rating scale. Nine of 38 patients in the ropivacaine group and 26 of 38 patients in the placebo group experienced shoulder pain during the first 6 h after surgery (absolute risk reduction 44% (95% CI 22-67%), relative risk reduction 65% (95% CI 41-80%); p = 0.00009). No major complications, including respiratory compromise or nerve injury, were observed. We conclude that ultrasound-guided supraclavicular phrenic nerve block is an effective technique for reducing the incidence of ipsilateral shoulder pain after thoracic surgery. © 2016 The Association of Anaesthetists of Great Britain and Ireland.

Cross-industry standard process for data mining is applicable to the lung cancer surgery domain, improving decision making as well as knowledge and quality management.

PubMed

Rivo, Eduardo; de la Fuente, Javier; Rivo, Ángel; García-Fontán, Eva; Cañizares, Miguel-Ángel; Gil, Pedro

2012-01-01

The aim of this study was to assess the applicability of knowledge discovery in database methodology, based upon data mining techniques, to the investigation of lung cancer surgery. According to CRISP 1.0 methodology, a data mining (DM) project was developed on a data warehouse containing records for 501 patients operated on for lung cancer with curative intention. The modelling technique was logistic regression. The finally selected model presented the following values: sensitivity 9.68%, specificity 100%, global precision 94.02%, positive predictive value 100% and negative predictive value 93.98% for a cut-off point set at 0.5. A receiver operating characteristic (ROC) curve was constructed. The area under the curve (CI 95%) was 0.817 (0.740- 0.893) (p < 0.05). Statistical association with perioperative mortality was found for the following variables [odds ratio (CI 95%)]: age over 70 [2.3822 (1.0338-5.4891)], heart disease [2.4875 (1.0089-6.1334)], peripheral arterial disease [5.7705 (1.9296-17.2570)], pneumonectomy [3.6199 (1.4939-8.7715)] and length of surgery (min) [1.0067 (1.0008-1.0126)]. The CRISP-DM process model is very suitable for lung cancer surgery analysis, improving decision making as well as knowledge and quality management.

Detecting the limits of bronchial closure methods in an animal model.

PubMed

Tezel, C; Urek, S; Keles, M; Kiral, H; Koşar, A; Dudu, C; Arman, B

2006-04-01

Bronchopleural fistula is a serious complication of major lung resections that may lead to mortality. An experimental animal model was designed to find out the safest bronchial closure method by comparing leakage rates under pressure. The tracheobronchial trees of 50 freshly dead sheep were prepared for either manual closure or closure with a stapler. After left pneumonectomy, the specimens were divided into five groups (n = 10); 3/0 Premilene suture was used with two "u" sutures + interrupted sutures in Group I; in Group II, 3/0 Premilene sutures with continuous horizontal mattress + over-over continuous sutures were used. In Group III and IV the same techniques were used with 3/0 Vicryl. A stapler was used in Group V. Specimens were intubated with an endotracheal tube, connected to a sphygmomanometer, and subsequently positioned under water. The pressure level at which we detected air bubbles indicated the limits of the technique. The median leakage pressure resistance was significantly lower in Group III (135 mm Hg) ( P = 0.001). The best results were achieved by using the continuous horizontal mattress + over-over continuous suture technique. No statistical significance difference was found between the stapler group, Groups I, II, and IV in terms of median leakage pressures. This trial suggests that manual suture closure using an appropriate technique and monofilament materials is as safe as the stapler.

Myofascial involvement of supra- and infraspinatus muscles contributes to ipsilateral shoulder pain after muscle-sparing thoracotomy and video-assisted thoracic surgery.

PubMed

Ohmori, Aki; Iranami, Hiroshi; Fujii, Keisuke; Yamazaki, Akinori; Doko, Yukari

2013-12-01

This study examined the hypothesis that ipsilateral upper extremity elevation for muscle-sparing thoracotomy procedures contributes to the postoperative shoulder pain. Prospective observational study. Medical center. ASA physical status 1-2 patients undergoing elective lung surgeries including pneumonectomy, lobectomy, and segmentectomy performed through either the anterolateral approach or video-assisted thoracotomy surgery. Postoperative observation of ipsilateral shoulder pain. Postoperative examinations of sites of shoulder pain (clavicle, anterior, lateral,or posterior aspect of acromion, posterior neck, supraspinatus, infraspinatus, and these entire areas) with or without trigger points, visual analog scale score of wound pain, and requested counts of analgesics. The number of patients who suffered from postoperative shoulder pain was 37 of 70 (52.9%). Demographic data, anterolateral/VATS ratio, VAS scores, and requested counts of rescue analgesics requirement were similar in the groups of patients with and without postoperative shoulder pain. The segmentectomy caused a significantly higher incidence of postoperative shoulder pain compared with other procedures (p < 0.05). The supra- and infraspinatus were significantly higher areas of painful regions compared to the other sites. The 16 of 37 patients (43.2%) with shoulder pain showed defined trigger points in their painful areas. These results supported the hypothesis that myofascial involvement contributed, to some extent, to shoulder pain after muscle-sparing thoracotomy with ipsilateral upper extremity elevation. Copyright © 2013 Elsevier Inc. All rights reserved.

Extraction of immune and inflammatory cells from human lung parenchyma: evaluation of an enzymatic digestion procedure.

PubMed Central

Holt, P G; Robinson, B W; Reid, M; Kees, U R; Warton, A; Dawson, V H; Rose, A; Schon-Hegrad, M; Papadimitriou, J M

1986-01-01

The inflammatory and immune cell populations of the human lung parenchyma have not been characterized in detail. This report describes a novel and efficient procedure for their extraction. Histologically normal human lung tissue samples from pneumonectomy specimens were sliced to 0.5 mm, and digested in collagenase/DNAse. Viable mononuclear cell yields ranged from 15-48 X 10(6)/g, and were markedly in excess of reported methods employing mechanical tissue disruption, which normally yield populations containing almost exclusively macrophages. The lung digest population was examined by flow cytometry using monoclonal antibodies against cell surface receptors, and found to comprise up to 40% T lymphocytes, 10% B lymphocytes and 30% macrophages, contaminated by less than 1% peripheral blood cells. Based upon these figures, the recoverable lung parenchymal lymphoid cell pool appears considerably larger than previously recognized, being of the same order as the peripheral blood pool. Initial functional studies suggest that such cellular activities as antigen-specific T cell proliferation, antigen-presentation, interleukin 1 production and natural killer cell activity survive the extraction process, and controlled enzymatic digestion experiments with peripheral blood cells indicate that the degree of enzyme-mediated damage to these functions and to cell-surface structures, was minimal. The extraction method thus appears suitable for studying the types and functions of human parenchymal lung cells in health and disease. Images Fig. 2 p195-a PMID:3026698

Thoracoplasty-Current View on Indication and Technique.

PubMed

Kuhtin, Oleg; Veith, Marina; Alghanem, Mohammed; Martel, Ivan; Giller, Dmitrii; Haas, Viktor; Lampl, Ludwig

2018-05-17

Thoracoplasty was invented for removing cavities between thoracic wall and remnant lung or mediastinum. It was initially used in cases of tuberculosis or unspecific infections, while currently it is used mainly for space problems after lobectomy/pneumonectomy.This article presents an overview of the historical and current techniques of this surgical procedure.Nowadays, thoracoplasty is rarely performed due to the low incidence of diseases for which this method is necessary. Therefore, this method has even been discredited. Furthermore, certain technical aspects of the thoracoplasty are not very well known because of the infrequent application of this procedure.Unfortunately, a look into the literature of thoracoplasty is not always usefull due to the biased views of advocates of different techniques such as Schede's thoracoplasty, Heller's Jalousie-Plastik, Alexander's extramusculoperiosteal thoracoplasty, Bjork's osteoplastic thoracoplasty, etc.Not to forget, there has always been a lack of research on the relevance and on the several techniques of thoracoplasty.The point is precise indication and correct execution of thoracoplasty as a final therapeutic option, which allows a safe and definitive solution of the space problem even in complex cases, without creating serious functional and cosmetic impairment for the patient.The main types of thoracoplasty are described in this article. Although the core principle of this operation remains unchanged, modern techniques are often cosmetically more considerable and less destructive, compared with techniques that were used in the past. Georg Thieme Verlag KG Stuttgart · New York.

[A case of multiple hepatocellular carcinoma with rapidly progressing bilateral portal vein tumor thrombosis--a complete remission achieved with dual treatment of reductive surgery plus percutaneous isolated hepatic perfusion].

PubMed

Tsuchida, Shinobu; Fukumoto, Takumi; Tominaga, Masahiro; Iwasaki, Takeshi; Kusunoki, Nobuya; Sugimoto, Takemi; Kido, Masahiro; Takebe, Atsushi; Tanaka, Motofumi; Hisoka, Kinoshita; Ku, Yonson

2005-10-01

We herein report a case of multiple advanced hepatocellular carcinoma (HCC) with rapidly progressing portal vein tumor thrombosis (PVTT). All of the hepatic tumors have completely disappeared for more than two years by a dual treatment with reductive surgery plus percutaneous isolated hepatic perfusion (PIHP). A 55-year-old man was referred to our institution on June 30, 2003. The abdominal CT scan demonstrated multiple massive HCC in the entire liver with PVTT reaching the portal trunk (Vp4). Two weeks later, the PVTT rapidly progressed to the umbilical portion of the left portal vein, and to the confluence of the superior mesenteric vein and to the splenic vein. Thus, we semi electively performed an extended right hepatectomy together with thrombectomy of the PVTT. Subsequently, he underwent a repeated PIHP (1st; doxorubicin 90 mg/m2, 2nd doxorubicin 65 mg/m2). This treatment produced complete tumor clearance of all of the residual tumors in the left liver. In March 2005, he underwent partial pneumonectomy for a metastatic lung. This again resulted in normalization of serum AFP and PIVKA-II levels. Dual treatment is considered to be the strongest therapeutic modality for multiple advanced HCC with severe PVTT. In addition, a close follow-up is required because in such far advanced cases, metastatic lesions most likely recur in the liver but also in the distant organs.

What can imaging tell us about physiology? Lung growth and regional mechanical strain.

PubMed

Hsia, Connie C W; Tawhai, Merryn H

2012-09-01

The interplay of mechanical forces transduces diverse physico-biochemical processes to influence lung morphogenesis, growth, maturation, remodeling and repair. Because tissue stress is difficult to measure in vivo, mechano-sensitive responses are commonly inferred from global changes in lung volume, shape, or compliance and correlated with structural changes in tissue blocks sampled from postmortem-fixed lungs. Recent advances in noninvasive volumetric imaging technology, nonrigid image registration, and deformation analysis provide valuable tools for the quantitative analysis of in vivo regional anatomy and air and tissue-blood distributions and when combined with transpulmonary pressure measurements, allow characterization of regional mechanical function, e.g., displacement, strain, shear, within and among intact lobes, as well as between the lung and the components of its container-rib cage, diaphragm, and mediastinum-thereby yielding new insights into the inter-related metrics of mechanical stress-strain and growth/remodeling. Here, we review the state-of-the-art imaging applications for mapping asymmetric heterogeneous physical interactions within the thorax and how these interactions permit as well as constrain lung growth, remodeling, and compensation during development and following pneumonectomy to illustrate how advanced imaging could facilitate the understanding of physiology and pathophysiology. Functional imaging promises to facilitate the formulation of realistic computational models of lung growth that integrate mechano-sensitive events over multiple spatial and temporal scales to accurately describe in vivo physiology and pathophysiology. Improved computational models in turn could enhance our ability to predict regional as well as global responses to experimental and therapeutic interventions.

Current issues in malignant pleural mesothelioma evaluation and management.

PubMed

Ai, Jing; Stevenson, James P

2014-09-01

Malignant pleural mesothelioma (MPM) is an uncommon disease most often associated with occupational asbestos exposure and is steadily increasing in worldwide incidence. Patients typically present at an older age, with advanced clinical stage and other medical comorbidities, making management quite challenging. Despite great efforts, the prognosis of MPM remains poor, especially at progression after initial treatment. Macroscopic complete resection of MPM can be achieved through extrapleural pneumonectomy (EPP) or extended (ie, radical) pleurectomy (e-P/D) in selected patients and can result in prolonged survival when incorporated into a multimodality approach. Given the morbidity associated with surgical resection of MPM, optimizing identification of appropriate patients is essential. Unfortunately, most patients are not candidates for EPP or e-P/D due to advanced stage, age, and/or medical comorbidity. Pemetrexed and platinum combination chemotherapy has become the cornerstone of therapy for patients with unresectable disease because the combination is associated with improved survival and quality of life in treated patients. However, MPM eventually becomes resistant to initial therapy, and benefit to further lines of therapy has not been substantiated in randomized clinical trials. Translational research has provided exciting insights into tumorigenesis, biomarkers, and immune response in MPM, leading to the development of multiple novel therapeutic agents that are currently in clinical trials. These advances hold the promise of a new era in the treatment of MPM and suggest that this disease will not be left behind in the war on cancer. ©AlphaMed Press.

Uniportal video-assisted thoracoscopic surgery: safety, efficacy and learning curve during the first 250 cases in Quebec, Canada.

PubMed

Drevet, Gabrielle; Ugalde Figueroa, Paula

2016-03-01

Video-assisted thoracoscopic surgery (VATS) using a single incision (uniportal) may result in better pain control, earlier mobilization and shorter hospital stays. Here, we review the safety and efficiency of our initial experience with uniportal VATS and evaluate our learning curve. We conducted a retrospective review of uniportal VATS using a prospectively maintained departmental database and analyzed patients who had undergone a lung anatomic resection separately from patients who underwent other resections. To assess the learning curve, we compared the first 10 months of the study period with the second 10 months. From January 2014 to August 2015, 250 patients underwent intended uniportal VATS, including 180 lung anatomic resections (72%) and 70 other resections (28%). Lung anatomic resection was successfully completed using uniportal VATS in 153 patients (85%), which comprised all the anatomic segmentectomies (29 patients), 80% (4 of 5) of the pneumonectomies and 82% (120 of 146) of the lobectomies attempted. The majority of lung anatomic resections that required conversion to thoracotomy occurred in the first half of our study period. Seventy patients underwent other uniportal VATS resections. Wedge resections were the most common of these procedures (25 patients, 35.7%). Although 24 of the 70 patients (34%) required the placement of additional ports, none required conversion to thoracotomy. Uniportal VATS was safe and feasible for both standard and complex pulmonary resections. However, when used for pulmonary anatomic resections, uniportal VATS entails a steep learning curve.

Unusual cardiac paraganglioma mimicking an atypical carcinoid tumor of the lung

PubMed Central

Evans, Mark; Wang, Beverly; Delrosario, J. Lawrence; Cheng, Timmy; Milliken, Jeffrey

2018-01-01

We present a case of unusual cardiac paraganglioma (PG) initially misdiagnosed as atypical carcinoid tumor of the lung and discuss key clinical and pathologic characteristics that guide surgical management of these rare chromaffin cell tumors. A 64-year-old female with persistent cough and back pain was found to have a 4 cm × 3 cm mass abutting multiple cardiopulmonary structures. A biopsy was performed at an outside institution and pathology reported “atypical neuroendocrine carcinoma, consistent with carcinoid”. The patient was transferred to our institution and pericardial resection with right pneumonectomy was performed to excise the tumor. Histology of the mass was that of PG with multiple ethanol embolizations. Immunohistochemical examination revealed that type I (chief) cells were positive for neuroendocrine markers (chromogranin A and synaptophysin), while type II (sustentacular) cells were positive for S100. There was no evidence of atypical carcinoid tumor in the lung. PG is an entity of chromaffin cell tumors that often affects the adrenal glands and carotid body. PG rarely occurs in the thoracic region, accounting for just 1–2% of all PG. Proper diagnosis of cardiac PG is challenging owing to its rare prevalence, subtle symptoms of presentation, and the neuroendocrine histopathological features it shares with atypical carcinoids. These tumors are typically benign and are best treated by surgical resection. Our report examines the approach to appropriate diagnosis of cardiac PG vs. atypical carcinoid, preoperative management, and surgical treatment by describing successful resection through thoracotomy without the use of cardiopulmonary bypass. PMID:29600100

Intravascular Placement of Metallic Coils as Lung Tumor Markers for CyberKnife Stereotactic Radiation Therapy.

PubMed

Karaman, Kutlay; Dokdok, A Murat; Karadeniz, Oktay; Ceylan, Cemile; Engin, Kayıhan

2015-01-01

To present our experience with placing endovascular coils in pulmonary arteries used as a fiducial marker for CyberKnife therapy and to describe the technical details and complications of the procedure. Between June 2005 and September 2013, 163 patients with primary or secondary lung malignancies, referred for fiducial placement for stereotactic radiosurgery, were retrospectively reviewed. Fourteen patients (9 men, 5 women; mean age, 70 years) with a history of pneumonectomy (n = 3), lobectomy (n = 3) or with severe cardiopulmonary co-morbidity (n = 8) underwent coil (fiducial marker) placement. Pushable or detachable platinum micro coils (n = 49) 2-3 mm in size were inserted through coaxial microcatheters into a small distal pulmonary artery in the vicinity of the tumor under biplane angiography/fluoroscopy guidance. Forty nine coils with a median number of 3 coils per tumor were placed with a mean tumor-coil distance of 2.7 cm. Forty three (87.7%) of 49 coils were successfully used as fiducial markers. Two coils could not be used due to a larger tumor-coil distance (> 50 mm). Four coils were in an acceptable position but their non-coiling shape precluded tumor tracking for CyberKnife treatment. No major complications needing further medication other than nominal therapy, hospitalization more than one night or permanent adverse sequale were observed. Endovascular placement of coil as a fiducial marker is safe and feasible during CyberKnife therapy, and might be an option for the patients in which percutaneous transthoracic fiducial placement might be risky.

The influence of complications on the costs of complex cancer surgery.

PubMed

Short, Marah N; Aloia, Thomas A; Ho, Vivian

2014-04-01

It is widely known that outcomes after cancer surgery vary widely, depending on interactions between patient, tumor, neoadjuvant therapy, and provider factors. Within this complex milieu, the influence of complications on the cost of surgical oncology care remains unknown. The authors examined rates of Patient Safety Indicator (PSI) occurrence for 6 cancer operations and their association with costs of care. The Agency for Healthcare Research and Quality (AHRQ) PSI definitions were used to identify patient safety-related complications in Medicare claims data. Hospital and inpatient physician claims for the years 2005 through 2009 were analyzed for 6 cancer resections: colectomy, rectal resection, pulmonary lobectomy, pneumonectomy, esophagectomy, and pancreatic resection. Risk-adjusted regression analyses were used to measure the association between each PSI and hospitalization costs. Overall PSI rates ranged from a low of 0.01% for postoperative hip fracture to a high of 2.58% for respiratory failure. Death among inpatients with serious treatable complications, postoperative respiratory failure, postoperative thromboembolism, and accidental puncture/laceration were >1% for all 6 cancer operations. Several PSIs-including decubitus ulcer, death among surgical inpatients with serious treatable complications, and postoperative thromboembolism-raised hospitalization costs by ≥20% for most cancer surgery types. Postoperative respiratory failure resulted in a cost increase >50% for all cancer resections. The consistently higher costs associated with cancer surgery PSIs indicate that substantial health care savings could be achieved by targeting these indicators for quality improvement. © 2013 American Cancer Society.

The influence of complications on the costs of complex cancer surgery

PubMed Central

Short, Marah N; Aloia, Thomas A; Ho, Vivian

2014-01-01

BACKGROUND It is widely known that outcomes after cancer surgery vary widely, depending on interactions between patient, tumor, neoadjuvant therapy, and provider factors. Within this complex milieu, the influence of complications on the cost of surgical oncology care remains unknown. The authors examined rates of Patient Safety Indicator (PSI) occurrence for 6 cancer operations and their association with costs of care. METHODS The Agency for Healthcare Research and Quality (AHRQ) PSI definitions were used to identify patient safety-related complications in Medicare claims data. Hospital and inpatient physician claims for the years 2005 through 2009 were analyzed for 6 cancer resections: colectomy, rectal resection, pulmonary lobectomy, pneumonectomy, esophagectomy, and pancreatic resection. Risk-adjusted regression analyses were used to measure the association between each PSI and hospitalization costs. RESULTS Overall PSI rates ranged from a low of 0.01% for postoperative hip fracture to a high of 2.58% for respiratory failure. Death among inpatients with serious treatable complications, postoperative respiratory failure, postoperative thromboembolism, and accidental puncture/laceration were >1% for all 6 cancer operations. Several PSIs—including decubitus ulcer, death among surgical inpatients with serious treatable complications, and postoperative thromboembolism—raised hospitalization costs by ≥20% for most cancer surgery types. Postoperative respiratory failure resulted in a cost increase >50% for all cancer resections. CONCLUSIONS The consistently higher costs associated with cancer surgery PSIs indicate that substantial health care savings could be achieved by targeting these indicators for quality improvement. PMID:24382697

What can imaging tell us about physiology? Lung growth and regional mechanical strain

PubMed Central

Tawhai, Merryn H.

2012-01-01

The interplay of mechanical forces transduces diverse physico-biochemical processes to influence lung morphogenesis, growth, maturation, remodeling and repair. Because tissue stress is difficult to measure in vivo, mechano-sensitive responses are commonly inferred from global changes in lung volume, shape, or compliance and correlated with structural changes in tissue blocks sampled from postmortem-fixed lungs. Recent advances in noninvasive volumetric imaging technology, nonrigid image registration, and deformation analysis provide valuable tools for the quantitative analysis of in vivo regional anatomy and air and tissue-blood distributions and when combined with transpulmonary pressure measurements, allow characterization of regional mechanical function, e.g., displacement, strain, shear, within and among intact lobes, as well as between the lung and the components of its container—rib cage, diaphragm, and mediastinum—thereby yielding new insights into the inter-related metrics of mechanical stress-strain and growth/remodeling. Here, we review the state-of-the-art imaging applications for mapping asymmetric heterogeneous physical interactions within the thorax and how these interactions permit as well as constrain lung growth, remodeling, and compensation during development and following pneumonectomy to illustrate how advanced imaging could facilitate the understanding of physiology and pathophysiology. Functional imaging promises to facilitate the formulation of realistic computational models of lung growth that integrate mechano-sensitive events over multiple spatial and temporal scales to accurately describe in vivo physiology and pathophysiology. Improved computational models in turn could enhance our ability to predict regional as well as global responses to experimental and therapeutic interventions. PMID:22582216

Predicted extracapsular invasion of hilar lymph node metastasis by fusion positron emission tomography/computed tomography in patients with lung cancer

PubMed Central

MAKINO, TAKASHI; HATA, YOSHINOBU; OTSUKA, HAJIME; KOEZUKA, SATOSHI; ISOBE, KAZUTOSHI; TOCHIGI, NOBUMI; SHIRAGA, NOBUYUKI; SHIBUYA, KAZUTOSHI; HOMMA, SAKAE; IYODA, AKIRA

2015-01-01

Intraoperative detection of hilar lymph node metastasis, particularly with extracapsular invasion, may affect the surgical procedure in patients with lung cancer, as the preoperative estimation of hilar lymph node metastasis is unsatisfactory. The aim of this study was to investigate whether fusion positron emission tomography/computed tomography (PET/CT) is able to predict extracapsular invasion of hilar lymph node metastasis. Between April, 2007 and April, 2013, 509 patients with primary lung cancer underwent surgical resection at our institution, among whom 28 patients exhibiting hilar lymph node metastasis (at stations 10 and 11) were enrolled in this study. A maximum lymph node standardized uptake value of >2.5 in PET scans was interpreted as positive. A total of 17 patients had positive preoperative PET/CT findings in their hilar lymph nodes, while the remaining 11 had negative findings. With regard to extracapsular nodal invasion, the PET/CT findings (P=0.0005) and the histological findings (squamous cell carcinoma, P=0.05) were found to be significant predictors in the univariate analysis. In the multivariate analysis, the PET/CT findings were the only independent predictor (P=0.0004). The requirement for extensive pulmonary resection (sleeve lobectomy, bilobectomy or pneumonectomy) was significantly more frequent in the patient group with positive compared with the group with negative PET/CT findings (76 vs. 9%, respectively, P=0.01). Therefore, the PET/CT findings in the hilar lymph nodes were useful for the prediction of extracapsular invasion and, consequently, for the estimation of possible extensive pulmonary resection. PMID:26623046

Predicted extracapsular invasion of hilar lymph node metastasis by fusion positron emission tomography/computed tomography in patients with lung cancer.

PubMed

Makino, Takashi; Hata, Yoshinobu; Otsuka, Hajime; Koezuka, Satoshi; Isobe, Kazutoshi; Tochigi, Nobumi; Shiraga, Nobuyuki; Shibuya, Kazutoshi; Homma, Sakae; Iyoda, Akira

2015-09-01

Intraoperative detection of hilar lymph node metastasis, particularly with extracapsular invasion, may affect the surgical procedure in patients with lung cancer, as the preoperative estimation of hilar lymph node metastasis is unsatisfactory. The aim of this study was to investigate whether fusion positron emission tomography/computed tomography (PET/CT) is able to predict extracapsular invasion of hilar lymph node metastasis. Between April, 2007 and April, 2013, 509 patients with primary lung cancer underwent surgical resection at our institution, among whom 28 patients exhibiting hilar lymph node metastasis (at stations 10 and 11) were enrolled in this study. A maximum lymph node standardized uptake value of >2.5 in PET scans was interpreted as positive. A total of 17 patients had positive preoperative PET/CT findings in their hilar lymph nodes, while the remaining 11 had negative findings. With regard to extracapsular nodal invasion, the PET/CT findings (P=0.0005) and the histological findings (squamous cell carcinoma, P=0.05) were found to be significant predictors in the univariate analysis. In the multivariate analysis, the PET/CT findings were the only independent predictor (P=0.0004). The requirement for extensive pulmonary resection (sleeve lobectomy, bilobectomy or pneumonectomy) was significantly more frequent in the patient group with positive compared with the group with negative PET/CT findings (76 vs. 9%, respectively, P=0.01). Therefore, the PET/CT findings in the hilar lymph nodes were useful for the prediction of extracapsular invasion and, consequently, for the estimation of possible extensive pulmonary resection.

Physiologic assessment before video thoracoscopic resection for lung cancer in patients with abnormal pulmonary function.

PubMed

Benattia, Amira; Debeaumont, David; Guyader, Vincent; Tardif, Catherine; Peillon, Christophe; Cuvelier, Antoine; Baste, Jean-Marc

2016-06-01

Impaired respiratory function may prevent curative surgery for patients with non-small cell lung cancer (NSCLC). Video-assisted thoracoscopic surgery (VATS) reduces postoperative morbility-mortality and could change preoperative assessment practices and therapeutic decisions. We evaluated the relation between preoperative pulmonary function tests and the occurrence of postoperative complications after VATS pulmonary resection in patients with abnormal pulmonary function. We included 106 consecutive patients with ≤80% predicted value of presurgical expiratory volume in one second (FEV1) and/or diffusing capacity of carbon monoxide (DLCO) and who underwent VATS pulmonary resection for NSCLC from a prospective surgical database. Patients (64±9.5 years) had lobectomy (n=91), segmentectomy (n=7), bilobectomy (n=4), or pneumonectomy (n=4). FEV1 and DLCO preoperative averages were 68%±21% and 60%±18%. Operative mortality was 1.89%. Only FEV1 was predictive of postoperative complications [odds ratio (OR), 0.96; 95% confidence interval (CI), 0.926-0.991, P=0.016], but there was no determinable threshold. Twenty-five patients underwent incremental exercise testing. Desaturations during exercise (OR, 0.462; 95% CI, 0.191-0.878, P=0.039) and heart rate (HR) response (OR, 0.953; 95% CI, 0.895-0.993, P=0.05) were associated with postoperative complications. FEV1 but not DLCO was a significant predictor of pulmonary complications after VATS pulmonary resection despite a low rate of severe morbidity. Incremental exercise testing seems more discriminating. Further investigation is required in a larger patient population to change current pre-operative threshold in a new era of minimally invasive surgery.

An overview of neoadjuvant chemotherapy in the multimodality treatment of malignant pleural mesothelioma.

PubMed

Pasello, G; Ceresoli, G L; Favaretto, A

2013-02-01

Malignant Pleural Mesothelioma (MPM) is an aggressive tumour with poor prognosis and increasing incidence in industrialized countries because of the previous widespread exposure to asbestos fibres and to the long lag period from time of exposure and the diagnosis of the disease. MPM shows high refractoriety to systemic treatment, single-modality treatment was generally ineffective and did not achieve higher results than supportive care. The incidence of local and distant recurrences after surgery remains high and that was the reason for many centres to perform combined treatments. In the attempt of reducing the incidence of local recurrences, a multimodality approach with surgery followed by adjuvant radiotherapy was explored. Extrapleural pneumonectomy (EPP) allows higher doses of radiotherapy to the whole hemithorax by avoiding pulmonary toxicity and the results of this approach is a significant reduction of loco-regional relapses; although, extrathoracic metastasis represent a major problem in the management of the disease because of the impact on overall survival. The success with surgical resection after neoadjuvant chemotherapy in stage IIIA lung cancer has been the impetus for several groups to apply this strategy in MPM aiming at reducing the incidence of distant relapse after surgery. Platinum-based chemotherapy plus gemcitabine or pemetrexed for 3-4 cycles followed by surgery and postoperative high-dose radiotherapy showed the best results in terms of overall and progression free survival. This review will focus on the main clinical studies and overview the results of different chemotherapy regimens in the neoadjuvant treatment of MPM. Copyright © 2012 Elsevier Ltd. All rights reserved.

The effects of thoracic surgery operations on quality of life: a multicenter study.

PubMed

Öz, Gürhan; Solak, Okan; Metin, Muzaffer; Esme, Hıdır; Sayar, Adnan

2015-10-01

Some treatment modalities may cause losses in patients' life comfort because of the treatment process. Our aim is to determine the effects of thoracic surgery operations on patients' quality of life. This is a multicenter and prospective study. A hundred patients, who had undergone posterolateral thoracotomy (PLT) and/or lateral thoracotomy (LT), were included in the study. A quality of life questionnaire (SF-36) was used to determine the changes in life comfort. SF-36 was performed before the operation, on the first month, third month, sixth month and twelfth month after the operation. Seventy-two percent (n = 72) of the patients were male. PLT was performed in 66% (n = 66) of the patients, and LT was performed in 34% (n = 34) of the patients. The types of resections in patients were pneumonectomy in four patients, lobectomy in 59 patients and wedge resection in 11 patients. No resection was performed in 26 patients. Thoracotomy caused deteriorations in physical function (PF), physical role (RP), bodily pain (BP), health, vitality and social function scores. The deteriorations observed in the third month improved in the sixth and twelfth months. The PF, RP, BP and MH scores of the patients with lung resection were much more worsened compared with the patients who did not undergo lung resection. Thoracic surgery operations caused substantial dissatisfaction in life comfort especially in the third month postoperatively. The worsening in physical function, physical role, pain and mental health is much more in patients with resection compared with the patients who did not undergo resection. © 2014 John Wiley & Sons Ltd.

Diversity of Interstitial Lung Fibroblasts Is Regulated by Platelet-Derived Growth Factor Receptor α Kinase Activity.

PubMed

Green, Jenna; Endale, Mehari; Auer, Herbert; Perl, Anne-Karina T

2016-04-01

Epithelial-mesenchymal cell interactions and factors that control normal lung development are key players in lung injury, repair, and fibrosis. A number of studies have investigated the roles and sources of epithelial progenitors during lung regeneration; such information, however, is limited in lung fibroblasts. Thus, understanding the origin, phenotype, and roles of fibroblast progenitors in lung development, repair, and regeneration helps address these limitations. Using a combination of platelet-derived growth factor receptor α-green fluorescent protein (PDGFRα-GFP) reporter mice, microarray, real-time polymerase chain reaction, flow cytometry, and immunofluorescence, we characterized two distinct interstitial resident fibroblasts, myo- and matrix fibroblasts, and identified a role for PDGFRα kinase activity in regulating their activation during lung regeneration. Transcriptional profiling of the two populations revealed a myo- and matrix fibroblast gene signature. Differences in proliferation, smooth muscle actin induction, and lipid content in the two subpopulations of PDGFRα-expressing fibroblasts during alveolar regeneration were observed. Although CD140α(+)CD29(+) cells behaved as myofibroblasts, CD140α(+)CD34(+) appeared as matrix and/or lipofibroblasts. Gain or loss of PDGFRα kinase activity using the inhibitor nilotinib and a dominant-active PDGFRα-D842V mutation revealed that PDGFRα was important for matrix fibroblast differentiation. We demonstrated that PDGFRα signaling promotes alveolar septation by regulating fibroblast activation and matrix fibroblast differentiation, whereas myofibroblast differentiation was largely PDGFRα independent. These studies provide evidence for the phenotypic and functional diversity as well as the extent of specificity of interstitial resident fibroblasts differentiation during regeneration after partial pneumonectomy.

Diversity of Interstitial Lung Fibroblasts Is Regulated by Platelet-Derived Growth Factor Receptor α Kinase Activity

PubMed Central

Green, Jenna; Endale, Mehari; Auer, Herbert

2016-01-01

Epithelial–mesenchymal cell interactions and factors that control normal lung development are key players in lung injury, repair, and fibrosis. A number of studies have investigated the roles and sources of epithelial progenitors during lung regeneration; such information, however, is limited in lung fibroblasts. Thus, understanding the origin, phenotype, and roles of fibroblast progenitors in lung development, repair, and regeneration helps address these limitations. Using a combination of platelet-derived growth factor receptor α–green fluorescent protein (PDGFRα-GFP) reporter mice, microarray, real-time polymerase chain reaction, flow cytometry, and immunofluorescence, we characterized two distinct interstitial resident fibroblasts, myo- and matrix fibroblasts, and identified a role for PDGFRα kinase activity in regulating their activation during lung regeneration. Transcriptional profiling of the two populations revealed a myo- and matrix fibroblast gene signature. Differences in proliferation, smooth muscle actin induction, and lipid content in the two subpopulations of PDGFRα-expressing fibroblasts during alveolar regeneration were observed. Although CD140α+CD29+ cells behaved as myofibroblasts, CD140α+CD34+ appeared as matrix and/or lipofibroblasts. Gain or loss of PDGFRα kinase activity using the inhibitor nilotinib and a dominant-active PDGFRα-D842V mutation revealed that PDGFRα was important for matrix fibroblast differentiation. We demonstrated that PDGFRα signaling promotes alveolar septation by regulating fibroblast activation and matrix fibroblast differentiation, whereas myofibroblast differentiation was largely PDGFRα independent. These studies provide evidence for the phenotypic and functional diversity as well as the extent of specificity of interstitial resident fibroblasts differentiation during regeneration after partial pneumonectomy. PMID:26414960

Curved cutter stapler for the application of bronchial sutures in anatomic pulmonary resections: the clinical experience of 139 cases.

PubMed

Sardelli, Paolo; Barrettara, Barbara; Cisternino, Marco Luigi; Napoli, Gaetano; Lacitignola, Angelo; Quitadamo, Stefania

2012-03-01

One of the fundamental steps in an anatomical pulmonary resection is the main and lobar bronchus suture. Nowadays, two different types of staplers are on the market: the linear TA stapler for open surgery (Tyco Healthcare Group LP, Norwalk, CT, USA), which is based on a 'guillotine' mechanism, sewing, but not cutting the bronchus, and the endoscopic linear stapler which both cuts and sews. This study aimed to fill the void in the use of an instrument used to staple and cut at the same time in 'open' thoracic surgery, eliminating the need for a scalpel: the curved cutter stapler (Contour Curved Cutter Stapler; Ethicon Endo-Surgery, Inc., Cincinnati, OH, USA). Between May 2009 and March 2011, the Contour Curved Stapler (Ethicon) was used for the bronchus in 139 cases of non-small cell lung carcinoma (NSCLC)-29 females and 110 males ranging between 48 and 85 years (average 71.1)-and comprising 115 lobectomies (8 bilobectomies) and 24 pneumonectomies (8 on the right lung, 16 on the left lung). All patients underwent a bronchoscopic check-up 30 days after they were discharged: in all cases, the bronchial stump was clearly within normal limits. No cases of bronchopleural fistulas were observed in the 139 patients. On the basis of this study, the curved cutter stapler showed to be a satisfactory device for securing the bronchus during an anatomic resection (whether lobar or main), in 'open' thoracic surgery. However, even though there were no cases of fistula, we consider that our data is still too limited to be statistically significant.

Surgeon-nurse anesthetist collaboration advanced surgery between 1889 and 1950.

PubMed

Koch, Bruce Evan

2015-03-01

To meet the need for qualified anesthetists, American surgeons recruited nurses to practice anesthesia during the Civil War and in the latter half of the 19th century. The success of this decision led them to collaborate with nurses more formally at the Mayo Clinic in Minnesota. During the 1890s, Alice Magaw refined the safe administration of ether. Florence Henderson continued her work improving the safety of ether administration during the first decade of the 20th century. Safe anesthesia enabled the Mayo surgeons to turn the St. Mary's Hospital into a surgical powerhouse. The prominent surgeon George Crile collaborated with Agatha Hodgins at the Lakeside Hospital in Cleveland to introduce nitrous oxide/oxygen anesthesia. Nitrous oxide/oxygen caused less cardiovascular depression than ether and thus saved the lives of countless trauma victims during World War I. Crile devised "anoci-association," an outgrowth of nitrous oxide/oxygen anesthesia. Hodgins' use of anoci-association made Crile's thyroid operations safer. Pioneering East Coast surgeons followed the lead of the surgeons at Mayo. William Halsted worked closely with Margaret Boise, and Harvey Cushing worked closely with Gertrude Gerard. As medicine became more complex, collaboration between surgeons and nurse anesthetists became routine and necessary. Teams of surgeons and nurse anesthetists advanced thoracic, cardiovascular, and pediatric surgery. The team of Evarts Graham and Helen Lamb performed the world's first pneumonectomy. Surgeon-nurse anesthetist collaboration seems to have been a uniquely American phenomenon. This collaboration facilitated both the "Golden Age of Surgery" and the profession we know today as nurse anesthesia.

Influence of Pulmonary Rehabilitation on Lung Function Changes After the Lung Resection for Primary Lung Cancer in Patients with Chronic Obstructive Pulmonary Disease.

PubMed

Mujovic, Natasa; Mujovic, Nebojsa; Subotic, Dragan; Ercegovac, Maja; Milovanovic, Andjela; Nikcevic, Ljubica; Zugic, Vladimir; Nikolic, Dejan

2015-11-01

Influence of physiotherapy on the outcome of the lung resection is still controversial. Study aim was to assess the influence of physiotherapy program on postoperative lung function and effort tolerance in lung cancer patients with chronic obstructive pulmonary disease (COPD) that are undergoing lobectomy or pneumonectomy. The prospective study included 56 COPD patients who underwent lung resection for primary non small-cell lung cancer after previous physiotherapy (Group A) and 47 COPD patients (Group B) without physiotherapy before lung cancer surgery. In Group A, lung function and effort tolerance on admission were compared with the same parameters after preoperative physiotherapy. Both groups were compared in relation to lung function, effort tolerance and symptoms change after resection. In patients with tumors requiring a lobectomy, after preoperative physiotherapy, a highly significant increase in FEV1, VC, FEF50 and FEF25 of 20%, 17%, 18% and 16% respectively was registered with respect to baseline values. After physiotherapy, a significant improvement in 6-minute walking distance was achieved. After lung resection, the significant loss of FEV1 and VC occurred, together with significant worsening of the small airways function, effort tolerance and symptomatic status. After the surgery, a clear tendency existed towards smaller FEV1 loss in patients with moderate to severe, when compared to patients with mild baseline lung function impairment. A better FEV1 improvement was associated with more significant loss in FEV1. Physiotherapy represents an important part of preoperative and postoperative treatment in COPD patients undergoing a lung resection for primary lung cancer.

Is Close Surveillance Indicated for Indolent Cancers? The Carcinoid Story.

PubMed

Murthy, Sudish C; Bariana, Christopher; Raja, Siva; Ahmad, Usman; Raymond, Daniel P; Rice, Thomas W; Wang, Robert; Ainkaran, Ponnuthurai; Houghtaling, Penny L; Blackstone, Eugene H

2016-01-01

The objective of this article is to determine the relevance of close postresection surveillance for bronchopulmonary carcinoid. From 2006 to 2013, 57 patients underwent lung resection for bronchopulmonary carcinoid. They were assessed for effects of clinical presentation, subtype, stage, and tobacco use on survival and recurrence. Utility of bronchoscopy and radiographic surveillance was reviewed. Mean follow-up was 2.1 ± 1.7 years. Carcinoid patients presented at a young age (51 ± 15 years) with normal spirometry regardless of smoking status (forced 1-second expiratory volume, 88% ± 19% for never smokers vs 87% ± 16% for smokers). Thirty-nine patients underwent a lobectomy (2 sleeve resections) and 11 pneumonectomy or bilobectomy. Most carcinoids were of the typical (n = 53, 93%) rather than atypical (n = 4, 7.0%) subtype. Staging from pathology was unaffected by smoking status. Eight patients had positive lymph nodes at resection (13% of typical and 25% of atypical subtypes). One recurrence was an atypical pN0 carcinoid. Of 57 patients, 18 were surveilled postoperatively with bronchoscopy, which revealed no recurrences. Furthermore, 146 follow-up computed tomography scans were performed on 53 of 57 patients. No typical carcinoid recurrences were identified by any postresection surveillance technique, regardless of stage. Bronchopulmonary carcinoid is a different entity from non-small cell lung cancer and has low recurrence and mortality risks independent of smoking status. It is hard to justify close surveillance following complete resection of typical carcinoid. Computed tomography scans at 5-year intervals might be reasonable and more cost effective. Copyright © 2016 Elsevier Inc. All rights reserved.

Impact of processes of care aimed at complication reduction on the cost of complex cancer surgery

PubMed Central

Ho, Vivian; Aloia, Thomas A.

2015-01-01

Background and Objectives Health care providers add multiple processes to the care of complex cancer patients, believing they prevent and/or ameliorate complications. However, the relationship between these processes, complication remediation, and expenditures is unknown. Methods Data for patients with cancer diagnoses undergoing colectomy, rectal resection, pulmonary lobectomy, pneumonectomy, esophagectomy, and pancreatic resection were obtained from hospital and inpatient physician Medicare claims for the years 2005–2009. Risk‐adjusted regression analyses measured the association between hospitalization costs and processes presumed to prevent and/or remedy complications common to high‐risk procedures. Results After controlling for comorbidities, analysis identified associations between increased costs and use of multiple processes, including arterial lines (4–12% higher; P < 0.001) and pulmonary artery catheters (23–33% higher; P < 0.001). Epidural analgesia was not associated with higher costs. Consultations were associated with 24‐44% (P < 0.001) higher costs, and total parenteral nutrition was associated with 13–31% higher costs (P < 0.001). Conclusions Many frequently utilized processes and services presumed to avoid and/or ameliorate complications are associated with increased surgical oncology costs. This suggests that the patient‐centered value of each process should be measured on a procedure‐specific basis. Likewise, further attention should be focused on defining the efficacy of each of these costly, but frequently unproven, additions to perioperative care. J. Surg. Oncol. 2015;112:610–615. © 2015 The Authors. Journal of Surgical Oncology Published by Wiley Periodicals, Inc. PMID:26391328

Benchmarking in Thoracic Surgery. Third Edition.

PubMed

Freixinet Gilart, Jorge; Varela Simó, Gonzalo; Rodríguez Suárez, Pedro; Embún Flor, Raúl; Rivas de Andrés, Juan José; de la Torre Bravos, Mercedes; Molins López-Rodó, Laureano; Pac Ferrer, Joaquín; Izquierdo Elena, José Miguel; Baschwitz, Benno; López de Castro, Pedro E; Fibla Alfara, Juan José; Hernando Trancho, Florentino; Carvajal Carrasco, Ángel; Canalís Arrayás, Emili; Salvatierra Velázquez, Ángel; Canela Cardona, Mercedes; Torres Lanzas, Juan; Moreno Mata, Nicolás

2016-04-01

Benchmarking entails continuous comparison of efficacy and quality among products and activities, with the primary objective of achieving excellence. To analyze the results of benchmarking performed in 2013 on clinical practices undertaken in 2012 in 17 Spanish thoracic surgery units. Study data were obtained from the basic minimum data set for hospitalization, registered in 2012. Data from hospital discharge reports were submitted by the participating groups, but staff from the corresponding departments did not intervene in data collection. Study cases all involved hospital discharges recorded in the participating sites. Episodes included were respiratory surgery (Major Diagnostic Category 04, Surgery), and those of the thoracic surgery unit. Cases were labelled using codes from the International Classification of Diseases, 9th revision, Clinical Modification. The refined diagnosis-related groups classification was used to evaluate differences in severity and complexity of cases. General parameters (number of cases, mean stay, complications, readmissions, mortality, and activity) varied widely among the participating groups. Specific interventions (lobectomy, pneumonectomy, atypical resections, and treatment of pneumothorax) also varied widely. As in previous editions, practices among participating groups varied considerably. Some areas for improvement emerge: admission processes need to be standardized to avoid urgent admissions and to improve pre-operative care; hospital discharges should be streamlined and discharge reports improved by including all procedures and complications. Some units have parameters which deviate excessively from the norm, and these sites need to review their processes in depth. Coding of diagnoses and comorbidities is another area where improvement is needed. Copyright © 2015 SEPAR. Published by Elsevier Espana. All rights reserved.

Video assisted thoracoscopic and open chest surgery in diagnosis and treatment of malignant pleural diseases

PubMed Central

Waller, David A.

2017-01-01

Parenchymal cancers of lung, breast, gastrointestinal tract and ovaries as well as lymphomas and mesotheliomas are among the most common cancer types causing malignant effusions, though almost all tumour types have been reported to cause a malignant effusion. The prognosis heavily depends on patients’ response to systemic therapy however, regardless of the causing pathology and histopathologic form, malignant pleural disease is normally associated with a poor prognosis. To date, there are not sufficient data to allow accurate predictions of survival that would facilitate decision making for managing patients with malignant pleural diseases. Interventions are directed towards drainage of the effusion and, when appropriate, concurrent or subsequent pleurodesis or establishing long-term drainage to prevent re-accumulation. The rate of re-accumulation of the pleural effusion, the patient's prognosis, and the severity of the patient’s symptoms should guide the subsequent choice of therapy. In contemporary medicine, not many cancers have managed to generate as intense debates concerning treatment, as malignant pleural mesothelioma. The relative advantages of surgery, radiation, chemotherapy and any combination of the three are continuously reassessed and reconsidered, even though not always based on scientific evidence. The aim of surgery in mesothelioma may be prolongation of life, in addition to palliation of symptoms. Longer recovery periods from more extensive surgical procedures could be justified, in carefully selected patients. Surgical options include: Video assisted thoracoscopic (VATS) pleurodesis, VATS partial pleurectomy (VATS PP)—both parietal and visceral; open pleurectomy decortication (PD)—with an extended option (EPD) and extrapleural pneumonectomy (EPP). Current evidence implies that EPD can be performed reliably in specialised centres with good results, both in terms of mortality and survival; however, no operation has yet been shown to be beneficial in a prospective randomized controlled clinical trial. PMID:29078648

A nomogram to predict the survival of stage IIIA-N2 non-small cell lung cancer after surgery.

PubMed

Mao, Qixing; Xia, Wenjie; Dong, Gaochao; Chen, Shuqi; Wang, Anpeng; Jin, Guangfu; Jiang, Feng; Xu, Lin

2018-04-01

Postoperative survival of patients with stage IIIA-N2 non-small cell lung cancer (NSCLC) is highly heterogeneous. Here, we aimed to identify variables associated with postoperative survival and develop a tool for survival prediction. A retrospective review was performed in the Surveillance, Epidemiology, and End Results database from January 2004 to December 2009. Significant variables were selected by use of the backward stepwise method. The nomogram was constructed with multivariable Cox regression. The model's performance was evaluated by concordance index and calibration curve. The model was validated via an independent cohort from the Jiangsu Cancer Hospital Lung Cancer Center. A total of 1809 patients with stage IIIA-N2 NSCLC who underwent surgery were included in the training cohort. Age, sex, grade, histology, tumor size, visceral pleural invasion, positive lymph nodes, lymph nodes examined, and surgery type (lobectomy vs pneumonectomy) were identified as significant prognostic variables using backward stepwise method. A nomogram was developed from the training cohort and validated using an independent Chinese cohort. The concordance index of the model was 0.673 (95% confidence interval, 0.654-0.692) in training cohort and 0.664 in validation cohort (95% confidence interval, 0.614-0.714). The calibration plot showed optimal consistency between nomogram predicted survival and observed survival. Survival analyses demonstrated significant differences between different subgroups stratified by prognostic scores. This nomogram provided the individual survival prediction for patients with stage IIIA-N2 NSCLC after surgery, which might benefit survival counseling for patients and clinicians, clinical trial design and follow-up, as well as postoperative strategy-making. Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Specific features of non-small cell lung cancer in women: a retrospective study of 1738 cases diagnosed in Bas-Rhin between 1982 and 1997.

PubMed

Foeglé, Jacinthe; Hédelin, Guy; Lebitasy, Marie-Paule; Purohit, Ashok; Velten, Michel; Quoix, Elisabeth

2007-06-01

The literature suggests that lung cancer may represent a different disease in women compared with men and that gender specificities have been reported mostly in clinical trials patients. We conducted a retrospective, population-based study of a sample of 1738 patients diagnosed with a non-small cell lung cancer (NSCLC) in the department of Bas-Rhin (northeastern France) between 1982 and 1997. Our study aimed to describe symptoms at presentation, stage, histological distribution, treatment modalities, and survival, according to sex. Tobacco exposure differed significantly according to sex: 28.9% of women were nonsmokers versus 1.4% of the men. More NSCLC were metastatic at diagnosis in women than in men (41.1% versus 29.9%). Adenocarcinoma predominated in women (54.4%), whereas squamous cell carcinoma predominated in men (65.9%). Invasive procedures, such as transthoracic needle biopsy, contributed more frequently to histological diagnosis in women. Men and women underwent the same procedures for disease staging, excepted for the abdominal computed tomography scan, which was performed more frequently in women. Treatment also differed: in resectable disease, fewer pneumonectomies were performed in women; in locally advanced disease, the mean doses of thoracic irradiation were significantly lower in women (48.0 grays versus 55.5 grays); in metastatic-stage disease, fewer women received platin-based chemotherapy, but this difference was not significant. Sex was not a significant prognostic factor in our study, contrary to most North American studies, where women seem to have had better survival rates. This study emphasizes gender differences in smoking exposure, presentation (stage, histological subtype), and diagnostic and therapeutic management of NSCLC.

Feasibility and efficacy of salvage lung resection after definitive chemoradiation therapy for Stage III non-small-cell lung cancer.

PubMed

Shimada, Yoshihisa; Suzuki, Kenji; Okada, Morihito; Nakayama, Haruhiko; Ito, Hiroyuki; Mitsudomi, Tetsuya; Saji, Hisashi; Takamochi, Kazuya; Kudo, Yujin; Hattori, Aritoshi; Mimae, Takahiro; Aokage, Keiju; Nishii, Teppei; Tsuboi, Masahiro; Ikeda, Norihiko

2016-12-01

For highly selected patients with Stage III non-small-cell lung cancer (NSCLC) who relapse or have residual disease after definitive chemoradiotherapy, salvage lung resection is likely to be one of the options for local control and possible better prognosis. However, the long-term benefit has not been verified. We conducted a retrospective study on salvage surgery on a multicentre basis. Patients included in this study met the following criteria: (i) prior treatment of lung cancer with curative-intent radiotherapy (≥60 Gy); (ii) no a priori plans for induction multimodality therapy; (iii) confirmation of loco-regional recurrence or persistent tumour in the irradiated area; (iv) pretherapeutic pathological results of NSCLC and (v) Stage III disease prior to chemoradiotherapy. A total of 18 patients were eligible for evaluation (Stage IIIA/IIIB, 14/4). The prior median radiation therapy dose was 60 Gy (60-74 Gy), and the median time between the last day of radiotherapy and resection was 38 weeks. The indications for surgery were primary tumour regrowth (10 patients) or tumour persistence (8 patients). Surgical procedures included lobectomy in 13 patients and pneumonectomy in 5 patients. Postoperative complications occurred in 5 patients (28%) without perioperative death. Complete resection was shown in 16 patients (89%) and a complete pathological response in 5 patients (28%). The median follow-up time was 1405 days, and the 3-year overall survival and recurrence-free survival rates were 78 and 72%, respectively. In the highly selected Stage III NSCLC after curative-intent chemoradiation therapy, salvage surgery was safely performed and contributed to satisfactory long-term survival. © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Radiation Therapy-First Strategy After Surgery With or Without Adjuvant Chemotherapy in Stage IIIA-N2 Non-Small Cell Lung Cancer.

PubMed

Lee, Hyun Woo; Noh, O Kyu; Oh, Young-Taek; Choi, Jin-Hyuk; Chun, Mison; Kim, Hwan-Ik; Heo, Jaesung; Ahn, Mi Sun; Park, Seong Yong; Park, Rae Woong; Yoon, Dukyong

2016-03-01

Postoperative radiation therapy (PORT) and postoperative chemotherapy (POCT) can be administered as adjuvant therapies in patients with non-small cell lung cancer (NSCLC). The aim of this study was to present the clinical outcomes in patients treated with PORT-first with or without subsequent POCT in stage IIIA-N2 NSCLC. From January 2002 to November 2014, the conditions of 105 patients with stage IIIA-N2 NSCLC who received PORT-first with or without subsequent POCT were analyzed. PORT was initiated within 4 to 6 weeks after surgical resection. Platinum-based POCT was administered 3 to 4 weeks after the completion of PORT. We analyzed the outcomes and the clinical factors affecting survival. Of 105 patients, 43 (41.0%) received POCT with a median of 4 cycles (range, 2-6 cycles). The follow-up times ranged from 3 to 123 months (median, 30 months), and the 5-year overall survival (OS) was 40.2%. The 5-year OS of patients treated with PORT and POCT was significantly higher than that of patients with PORT (61.3% vs 29.2%, P<.001). The significant prognostic factors affecting OS were the use of POCT (hazard ratio [HR] = 0.453, P=.036) and type of surgery (pneumonectomy/lobectomy; HR = 2.845, P<.001). PORT-first strategy after surgery appeared not to compromise the clinical outcomes in the treatment of stage IIIA-N2 NSCLC. The benefit of POCT on OS was preserved even in the PORT-first setting. Further studies are warranted to compare the sequencing of PORT and POCT, guaranteeing the proper use of POCT. Copyright © 2016 Elsevier Inc. All rights reserved.

Blockade of the mental nerve for lower lip surgery as a safe alternative to general anesthesia in two very old patients.

PubMed

Tan, Ferdinand Frederik Som Ling; Schiere, Sjouke; Reidinga, Auke C; Wit, Fennie; Veldman, Peter Hjm

2015-01-01

Regional anesthesia is gaining popularity with anesthesiologists as it offers superb postoperative analgesia. However, as the sole anesthetic technique in high-risk patients in whom general anesthesia is not preferred, some regional anesthetic possibilities may be easily overlooked. By presenting two cases of very old patients with considerable comorbidities, we would like to bring the mental nerve field block under renewed attention as a safe alternative to general anesthesia and to achieve broader application of this simple nerve block. Two very old male patients (84 and 91 years) both presented with an ulcerative lesion at the lower lip for which surgical removal was scheduled. Because of their considerable comorbidities and increased frailty, bilateral blockade of the mental nerve was considered superior to general anesthesia. As an additional advantage for the 84-year-old patient, who had a pneumonectomy in his medical history, the procedure could be safely performed in a beach-chair position to prevent atelectasis and optimize the ventilation/perfusion ratio of the single lung. The mental nerve blockades were performed intraorally in a blind fashion, after eversion of the lip and identifying the lower canine. A 5 mL syringe with a 23-gauge needle attached was passed into the buccal mucosa until it approximated the mental foramen, where 2 mL of lidocaine 2% with adrenaline 1:100.000 was injected. The other side was anesthetized in a similar fashion. Both patients underwent the surgical procedure uneventfully under a bilateral mental nerve block and were discharged from the hospital on the same day. A mental nerve block is an easy-to-perform regional anesthetic technique for lower lip surgery. This technique might be especially advantageous in the very old, frail patient.

Bronchial adenoma: review of 18-year experience at the Brompton Hospital.

PubMed Central

Lawson, R M; Ramanathan, L; Hurley, G; Hinson, K W; Lennox, S C

1976-01-01

Continued uncertainty about the prognosis for patients with bronchial adenomata led to a review of the experience of this condition in the Brompton Hospital. Of 72 patients seen between January 1955 and December 1972, 39 were women and 33 men, mean age 45 years, range 9-73 years. The commonest presenting symptoms were haemoptysis, cough, sputum, and repeated chest infections. Positive bronchoscopic biopsy occurred in 35 of 43 cases; five of these were originally reported as carcinomata, of oat-cell type in four. Plain chest film abnormality occurred in 69 patients. Seventy-three operative procedures comprised two endoscopic removals, two wedge resections, six bronchotomies, five pneumonectomies, and 58 lobectomies (seven with sleeve resection). Recurrence in three of six bronchotomies--two with adenoid cystic carcinomata (cylindromata)--necessitated further surgery. Lobectomy and lymph node dissection is usually the operation of choice. Histology confirmed 67 carcinoids (eight with atypical histology or lymph node metastases), two adenoid cystic carcinomata, one muco-epidermoid, and two mucous gland adenomata. Prolonged follow-up is especially indicated in patients with adenoid cyst carcinoma and in those with atypical or metastatic carcinoid histology. Although such pathology is not incompatible with long survival, of 10 patients in these categories, all five late deaths were probably related to the tumour. However, of 57 patients considered to have had typical carcinoid histology and adequate removal of the tumour, there has to date been no tumour-related death, but one patient developed radiosensitive atypical carcinoid tracheal tumours nine years later. The actuarially assessed survival of 71 patients undergoing surgery for bronchial adenomata was 75% at 15 years. Specific tumour types should replace the term bronchial adenoma. Images PMID:181862

Dysregulated renin-angiotensin-aldosterone system contributes to pulmonary arterial hypertension

PubMed Central

De Man, Frances; Tu, Ly; Handoko, Louis; Rain, Silvia; Ruiter, Gerrina; François, Charlène; Schalij, Ingrid; Dorfmüller, Peter; Simonneau, Gérald; Fadel, Elie; Perros, Frederic; Boonstra, Anco; Postmus, Piet; Van Der Velden, Jolanda; Vonk-Noordegraaf, Anton; Humbert, Marc; Eddahibi, Saadia; Guignabert, Christophe

2012-01-01

Rationale Patients with idiopathic pulmonary arterial hypertension (iPAH) often have a low cardiac output. To compensate, neurohormonal systems like renin-angiotensin-aldosterone system (RAAS) and sympathetic nervous system are upregulated but this may have long-term negative effects on the progression of iPAH. Objectives Assess systemic and pulmonary RAAS-activity in iPAH-patients and determine the efficacy of chronic RAAS-inhibition in experimental PAH. Measurements and Main Results We collected 79 blood samples from 58 iPAH-patients in the VU University Medical Center Amsterdam (between 2004–2010), to determine systemic RAAS-activity. We observed increased levels of renin, angiotensin (Ang) I and AngII, which was associated with disease progression (p<0.05) and mortality (p<0.05). To determine pulmonary RAAS-activity, lung specimens were obtained from iPAH-patients (during lung transplantation, n=13) and controls (during lobectomy or pneumonectomy for cancer, n=14). Local RAAS-activity in pulmonary arteries of iPAH-patients was increased, demonstrated by elevated ACE-activity in pulmonary endothelial cells and increased AngII type 1 (AT1) receptor expression and signaling. In addition, local RAAS- upregulation was associated with increased pulmonary artery smooth muscle cell proliferation via enhanced AT1-receptor signaling in iPAH-patients compared to controls. Finally, to determine the therapeutic potential of RAAS-activity, we assessed the chronic effects of an AT1-receptor antagonist (losartan) in the monocrotaline PAH-rat model (60 mg/kg). Losartan delayed disease progression, decreased RV afterload and pulmonary vascular remodeling and restored right ventricular-arterial coupling in PAH-rats. Conclusions Systemic and pulmonary RAAS-activities are increased in iPAH-patients and associated with increased pulmonary vascular remodeling. Chronic inhibition of RAAS by losartan is beneficial in experimental PAH. PMID:22859525

Radiation Therapy–First Strategy After Surgery With or Without Adjuvant Chemotherapy in Stage IIIA-N2 Non-Small Cell Lung Cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lee, Hyun Woo; Noh, O Kyu, E-mail: okyu.noh@gmail.com; Oh, Young-Taek

Purpose: Postoperative radiation therapy (PORT) and postoperative chemotherapy (POCT) can be administered as adjuvant therapies in patients with non-small cell lung cancer (NSCLC). The aim of this study was to present the clinical outcomes in patients treated with PORT-first with or without subsequent POCT in stage IIIA-N2 NSCLC. Methods and Materials: From January 2002 to November 2014, the conditions of 105 patients with stage IIIA-N2 NSCLC who received PORT-first with or without subsequent POCT were analyzed. PORT was initiated within 4 to 6 weeks after surgical resection. Platinum-based POCT was administered 3 to 4 weeks after the completion of PORT. We analyzedmore » the outcomes and the clinical factors affecting survival. Results: Of 105 patients, 43 (41.0%) received POCT with a median of 4 cycles (range, 2-6 cycles). The follow-up times ranged from 3 to 123 months (median, 30 months), and the 5-year overall survival (OS) was 40.2%. The 5-year OS of patients treated with PORT and POCT was significantly higher than that of patients with PORT (61.3% vs 29.2%, P<.001). The significant prognostic factors affecting OS were the use of POCT (hazard ratio [HR] = 0.453, P=.036) and type of surgery (pneumonectomy/lobectomy; HR = 2.845, P<.001). Conclusions: PORT-first strategy after surgery appeared not to compromise the clinical outcomes in the treatment of stage IIIA-N2 NSCLC. The benefit of POCT on OS was preserved even in the PORT-first setting. Further studies are warranted to compare the sequencing of PORT and POCT, guaranteeing the proper use of POCT.« less

Robotic thoracic surgery: The state of the art

PubMed Central

Kumar, Arvind; Asaf, Belal Bin

2015-01-01

Minimally invasive thoracic surgery has come a long way. It has rapidly progressed to complex procedures such as lobectomy, pneumonectomy, esophagectomy, and resection of mediastinal tumors. Video-assisted thoracic surgery (VATS) offered perceptible benefits over thoracotomy in terms of less postoperative pain and narcotic utilization, shorter ICU and hospital stay, decreased incidence of postoperative complications combined with quicker return to work, and better cosmesis. However, despite its obvious advantages, the General Thoracic Surgical Community has been relatively slow in adapting VATS more widely. The introduction of da Vinci surgical system has helped overcome certain inherent limitations of VATS such as two-dimensional (2D) vision and counter intuitive movement using long rigid instruments allowing thoracic surgeons to perform a plethora of minimally invasive thoracic procedures more efficiently. Although the cumulative experience worldwide is still limited and evolving, Robotic Thoracic Surgery is an evolution over VATS. There is however a lot of concern among established high-volume VATS centers regarding the superiority of the robotic technique. We have over 7 years experience and believe that any new technology designed to make minimal invasive surgery easier and more comfortable for the surgeon is most likely to have better and safer outcomes in the long run. Our only concern is its cost effectiveness and we believe that if the cost factor is removed more and more surgeons will use the technology and it will increase the spectrum and the reach of minimally invasive thoracic surgery. This article reviews worldwide experience with robotic thoracic surgery and addresses the potential benefits and limitations of using the robotic platform for the performance of thoracic surgical procedures. PMID:25598601

[Complications in patients undergoing pulmonary oncological surgery].

PubMed

Mitás, L; Horváth, T; Sobotka, M; Garajová, B; Hanke, I; Kala, Z; Penka, I; Ivicic, J; Vomela, J

2010-02-01

A survey evaluating incidence and risk factors of complications in persons underwent complete open lung resection because of primary or secondary lung malignancy. Retrospective study of 189 open surgery procedures in 128 males and 61 females, mean age males 61 years (range 21-78), females 64 years (range 33-80) during a five-years period (2003-2007). Data processing and analysis were performed with the statistical software system Statistica and compared by parametres odds ratio a chi2 test. Complications were divided into five groups. First group was defined as complications in perioperative period and was composed of three events 1.5%: endotracheal tube dysfunction (i.e. 0.5%), heavy cardiac arrhytmia 0.5% and serious haemorrhage, that occurred immediately after operation 0.5%. Second group includes complications within period of 7 days after surgery: prolonged air leak (PAL > 7 days) 7.4%, bronchopneumonia 6.9%, cardiac arrhythmia 6.9%, postoperative delirium 4.2%, atelectasis 2.6%, wound infection 1.1%, bleeding 1.1% and chylothorax 0.5%. Third group contains events between 8th and 30th postoperative days: thoracic empyema 2.1%, dysphonia 2.1%, painfull shoulder 1.1%, alimentary tract infection 0.5% and bronchial closure insufficiency 0.5%. Fourth group contains patients with severe complications, that led to death during 30 days after operation: ischemic stroke 0.5% and pulmonary embolism 0.5%. Patients without any complication formed the fifth group of 60.5%. Main risk factors for complications in postoperative period after lung resection due to primary or secondary lung malignancy in our group of patients are COPD, corticotherapy, time of operation over 3 hours, BMI over 25, left side tumor localization and bronchoplastic procedure. For cardiac arrhytmia seems to be risk factor pneumonectomy and previous neoadjuvant radiochemotherapy.

Ninety-day mortality after resection for lung cancer is nearly double 30-day mortality.

PubMed

Pezzi, Christopher M; Mallin, Katherine; Mendez, Andres Samayoa; Greer Gay, Emmelle; Putnam, Joe B

2014-11-01

To evaluate 30-day and 90-day mortality after major pulmonary resection for lung cancer including the relationship to hospital volume. Major lung resections from 2007 to 2011 were identified in the National Cancer Data Base. Mortality was compared according to annual volume and demographic and clinical covariates using univariate and multivariable analyses, and included information on comorbidity. Statistical significance (P<.05) and 95% confidence intervals were assessed. There were 124,418 major pulmonary resections identified in 1233 facilities. The 30-day mortality rate was 2.8%. The 90-day mortality rate was 5.4%. Hospital volume was significantly associated with 30-day mortality, with a mortality rate of 3.7% for volumes less than 10, and 1.7% for volumes of 90 or more. Other variables significantly associated with 30-day mortality include older age, male sex, higher stage, pneumonectomy, a previous primary cancer, and multiple comorbidities. Similar results were found for 90-day mortality rates. In the multivariate analysis, hospital volume remained significant with adjusted odds ratios of 2.1 (95% confidence interval [CI], 1.7-2.6) for 30-day mortality and 1.3 (95% CI, 1.1-1.6) for conditional 90-day mortality for the hospitals with the lowest volume (<10) compared with those with the highest volume (>90). Hospitals with a volume less than 30 had an adjusted odds ratio for 30-day mortality of 1.3 (95% CI, 1.2-1.5) compared with those with a volume greater than 30. Mortality at 30 and 90 days and hospital volume should be monitored by institutions performing major pulmonary resection and benchmarked against hospitals performing at least 30 resections per year. Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Compliance with post-operative adjuvant chemotherapy in non-small cell lung cancer. An analysis of National Cancer Institute of Canada and intergroup trial JBR.10 and a review of the literature.

PubMed

Alam, Naveed; Shepherd, Frances A; Winton, Timothy; Graham, Barbara; Johnson, David; Livingston, Robert; Rigas, James; Whitehead, Marlo; Ding, Keyue; Seymour, Lesley

2005-03-01

Resected non-small cell lung cancer (NSCLC) has 5-years survival rates of 30-70%. The role of adjuvant chemotherapy remains unclear with poor compliance reported in most trials. The compliance with adjuvant chemotherapy (ACT) for stage IB and II NSCLC was analyzed using data from a North American multi-centre phase III study (accrual 1994-2001) that compared adjuvant chemotherapy to observation. Planned chemotherapy consisted of cisplatin (CIS) 50 mg/m2 days 1, 8 and vinorelbine (VIN) 25 mg/m2 days 1, 8, 15, 22 for four cycles; the VIN dose had been reduced from 30 mg/m2 after an initial cohort of patients experienced unacceptable toxicity. Four hundred and twenty-four patients were randomized after the amendment, 215 to the chemotherapy arm. Median age was 60 years, 64% were male and 84% had stage II disease. Thirty-seven patients completed one cycle, 14 completed two, 20 completed three and 108 patients completed all four cycles. Ten patients received no therapy. Multivariate analysis demonstrated statistically significant differences in compliance with extent of surgery, gender and age. Patients randomized in Canada were more likely to fail to complete chemotherapy due to refusal of therapy than their American counterparts. Patients who had pneumonectomies were more likely to discontinue therapy due to toxicity than those who had lesser resections. Extent of surgery may play a role in both the compliance and toxicity of ACT. Differences between nations in the perception of the risks and benefits of adjuvant chemotherapy regimens, both between physicians and patients, should be investigated further.

[Indication for limited surgery on small lung cancer tumors measuring 1cm or less in diameter on preoperative computed tomography and long-term results].

PubMed

Togashi, K; Koike, T; Emura, I; Usuda, H

2008-07-01

Non-invasive lung cancers showed a good prognosis after limited surgery. But it is still uncertain about invasive lung cancers. We investigated the indications for limited surgery for small lung cancer tumors measuring 1 cm or less in diameter on preoperative computed tomography (CT). This study retrospectively analyzed of 1,245 patients who underwent complete resection of lung cancer between 1989 and 2004 in our hospital. Sixty-two patients (5%) had tumors measuring 1 cm or less in diameter. The probability of survival was calculated using the Kaplan-Meier method. All diseases were detected by medical checkup, 52 % of the patients were not definitively diagnosed with lung cancer before surgery. Adenocarcinoma was histologically diagnosed in 49 patients (79%). Other histologic types included squamous cell carcinoma (8), large cell carcinoma (1), small cell carcinoma (1), carcinoid (2), and adenosquamous cell carcinoma (1). Fifty-seven patients (92%) showed pathologic stage IA. The other stages were IB (2), IIA (1), and IIIB (2). There were 14 bronchioloalveolar carcinomas (25% of IA diseases). The 5-year survival rates of IA patients were 90%. The 5-year survival rate of patients with tumors measuring 1cm or less diameter was 91% after lobectomy or pneumonectomy, and 90% after wedge resection or segmentectomy. There were 3 deaths from cancer recurrence, while there were no deaths in 14 patients with bronchioloalveolar carcinoma After limited surgery, non-invasive cancer showed good long-term results, while invasive cancer showed a recurrence rate of 2.3% to 79% even though the tumor measured 1 cm or less in diameter on preoperative CT.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Patel, Pretesh R., E-mail: patel073@mc.duke.edu; Yoo, Sua; Broadwater, Gloria

Purpose: To assess the impact of increasing experience with intensity-modulated radiation therapy (IMRT) after extrapleural pneumonectomy (EPP) for malignant pleural mesothelioma (MPM). Methods and Materials: The records of all patients who received IMRT following EPP at Duke University Medical Center between 2005 and 2010 were reviewed. Target volumes included the preoperative extent of the pleural space, chest wall incisions, involved nodal stations, and a boost to close/positive surgical margins if applicable. Patients were typically treated with 9-11 beams with gantry angles, collimator rotations, and beam apertures manually fixed to avoid the contalateral lung and to optimize target coverage. Toxicity wasmore » graded retrospectively using National Cancer Institute common toxicity criteria version 4.0. Target coverage and contralateral lung irradiation were evaluated over time by using linear regression. Local control, disease-free survival, and overall survival rates were estimated using the Kaplan-Meier method. Results: Thirty patients received IMRT following EPP; 21 patients also received systemic chemotherapy. Median follow-up was 15 months. The median dose prescribed to the entire ipsilateral hemithorax was 45 Gy (range, 40-50.4 Gy) with a boost of 8-25 Gy in 9 patients. Median survival was 23.2 months. Two-year local control, disease-free survival, and overall survival rates were 47%, 34%, and 50%, respectively. Increasing experience planning MPM cases was associated with improved coverage of planning target volumes (P=.04). Similarly, mean lung dose (P<.01) and lung V5 (volume receiving 5 Gy or more; P<.01) values decreased with increasing experience. Lung toxicity developed after IMRT in 4 (13%) patients at a median of 2.2 months after RT (three grade 3-4 and one grade 5). Lung toxicity developed in 4 of the initial 15 patients vs none of the last 15 patients treated. Conclusions: With increasing experience, target volume coverage improved and dose to the contralateral lung decreased. Rates of pulmonary toxicity were relatively low. However, both local and distant control rates remained suboptimal.« less

Closure of a Recurrent Bronchopleural Fistula Using a Matrix Seeded With Patient-Derived Mesenchymal Stem Cells.

PubMed

Aho, Johnathon M; Dietz, Allan B; Radel, Darcie J; Butler, Greg W; Thomas, Mathew; Nelson, Timothy J; Carlsen, Brian T; Cassivi, Stephen D; Resch, Zachary T; Faubion, William A; Wigle, Dennis A

2016-10-01

: Management of recurrent bronchopleural fistula (BPF) after pneumonectomy remains a challenge. Although a variety of devices and techniques have been described, definitive management usually involves closure of the fistula tract through surgical intervention. Standard surgical approaches for BPF incur significant morbidity and mortality and are not reliably or uniformly successful. We describe the first-in-human application of an autologous mesenchymal stem cell (MSC)-seeded matrix graft to repair a multiply recurrent postpneumonectomy BPF. Adipose-derived MSCs were isolated from patient abdominal adipose tissue, expanded, and seeded onto bio-absorbable mesh, which was surgically implanted at the site of BPF. Clinical follow-up and postprocedural radiological and bronchoscopic imaging were performed to ensure BPF closure, and in vitro stemness characterization of patient-specific MSCs was performed. The patient remained clinically asymptomatic without evidence of recurrence on bronchoscopy at 3 months, computed tomographic imaging at 16 months, and clinical follow-up of 1.5 years. There is no evidence of malignant degeneration of MSC populations in situ, and the patient-derived MSCs were capable of differentiating into adipocytes, chondrocytes, and osteocytes using established protocols. Isolation and expansion of autologous MSCs derived from patients in a malnourished, deconditioned state is possible. Successful closure and safety data for this approach suggest the potential for an expanded study of the role of autologous MSCs in regenerative surgical applications for BPF. Bronchopleural fistula is a severe complication of pulmonary resection. Current management is not reliably successful. This work describes the first-in-human application of an autologous mesenchymal stem cell (MSC)-seeded matrix graft to the repair of a large, multiply recurrent postpneumonectomy BPF. Clinical follow-up of 1.5 years without recurrence suggests initial safety and feasibility of this approach. Further assessment of MSC grafts in these difficult clinical scenarios requires expanded study. ©AlphaMed Press.

Porcine pulmonary auto-transplantation for ex vivo therapy as a model for new treatment strategies.

PubMed

Krüger, Marcus; Zinne, Norman; Biancosino, Christian; Höffler, Klaus; Rajab, Taufiek K; Waldmann, Karl-Heinz; Jonigk, Danny; Avsar, Murat; Haverich, Axel; Hoeltig, Doris

2016-09-01

Lung auto-transplantation is the surgical key step in experiments involving ex vivo therapy of severe or end-stage lung diseases. Ex vivo therapy has become a clinical reality because of systems such as the Organ Care System (OCS) Lung, which is the only commercially available portable lung perfusion system. However, survival experiments involving porcine lung auto-transplantation pose special surgical and anaesthesiological challenges. This current study was designed to describe the development of surgical techniques and aneasthesiological management strategies that facilitate lung auto-transplantation survival surgery including a follow-up period of 4 days. Left pneumonectomy was performed in 12 Mini-Lewe miniature pigs. After ex vivo treatment of the harvested lungs within the OCS Lung for 2 h, the lungs were retransplanted into the same animal (auto-transplantation). Four animals were used to develop the optimal techniques and establish an experimental protocol. According to the final protocol, eight additional animals were operated. The follow-up period was 4 days. There were four severe intraoperative surgical complications [anatomical variant of the superior vena cava (two times), a complication related to the bronchial anastomosis and a complication related to the pulmonary arterial anastomosis]. The major postoperative problems were hyperkalaemia, prolonged recovery from anaesthesia and pulmonary oedema after reperfusion. Establishment of the surgical technique showed that using a pericardial tube to facilitate the anastomosis of the thin left superior pulmonary vein should be considered to prevent thrombosis. However, routine use of the patch technique to construct venous and arterial anastomoses is not necessary. Furthermore, traction on the venous anastomoses can be avoided by performing the bronchial anastomosis first. Lung auto-transplantation is a feasible experimental model for ex vivo therapy of lung diseases and is applicable for experimental questions concerning human lung transplantation. © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Optimal surgical approach to thymic malignancies: New trends challenging old dogmas.

PubMed

Ruffini, Enrico; Filosso, Pier Luigi; Guerrera, Francesco; Lausi, Paolo; Lyberis, Paraskevas; Oliaro, Alberto

2018-04-01

Until recently, the surgical approach to thymic tumors has remained basically unchanged. The collaborative effort led by ITMIG with the collaboration of regional and society-based interest groups (ESTS, JART) produced an enthusiastic surge of interest in testing the new technological advances in thoracic surgery and many historical dogmas in thymic surgery have been questioned and challenged. The present review addresses the new trends in the optimal surgical management of thymic tumors based on the review of the current literature. 1. Minimally-invasive techniques (MIT) including video-assisted thoracic surgery (VATS) and robotic-assisted thoracic Surgery (RATS) are now to be considered the standard of care in early-stage thymic tumors. MIT are no inferior to open approaches in terms of postoperative complications, loco-regional recurrence rates and survival. MIT are associated with a shorter length of stay, reduced intraoperative blood loss and better cosmetic results. 2. The adoption of the ITMIG/IASLC TNM staging system for thymic tumors requires a paradigm shift among thoracic surgeons to include regional lymphadenectomy according to the IASLC/ITMIG nodal map in the surgical management of thymic tumors. 3. A limited thymectomy instead of total thymectomy along with the removal of the thymic tumor in nonmyasthenic Stage I-II tumors has been proposed by some authors, although the results are not uniform. Until more mature data is available, adherence to the current guidelines recommending total thymectomy in addition to thymomectomy is always indicated. 4. In locally-advanced Stage IVa patients with pleural involvement, major pleural resections, including pleurectomy/decortication or extrapleural pneumonectomy are indicated, provided a complete resection of the pleural deposits is anticipated, usually in a multidisciplinary setting, with excellent long-term results. The incorporation of these new concepts and techniques in the surgical armamentarium of the thoracic surgeons dealing with thymic malignancies will certainly be of help in the optimal management of these patients. Copyright © 2018 Elsevier B.V. All rights reserved.

Robert R. Shaw, MD: thoracic surgical hero, Afghanistan medical pioneer, champion for the patient, never a surgical society president.

PubMed

Urschel, Harold C; Urschel, Betsey Bradley

2012-06-01

Dr Robert R. Shaw arrived in Dallas to practice Thoracic Surgery in 1937, as John Alexander's 7th Thoracic Surgical Resident from Michigan University Medical Center. Dr Shaw's modus operandi was, "You can accomplish almost anything, if you don't care who gets the credit." He was a remarkable individual who cared the most about the patient and very little about getting credit for himself. From 1937 to 1970, Dr Shaw established one of the largest lung cancer surgical centers in the world in Dallas, Texas. It was larger than M.D. Anderson and Memorial Sloan-Kettering Hospitals put together regarding the surgical treatment of lung cancer patients. To accomplish this, he had the help of Dr Donald L. Paulson, who trained at the Mayo Clinic and served as Chief of Thoracic Surgery at Brook Army Hospital during the Second World War. Following the War, because of his love for Texas, he ended up as a partner of Dr Shaw in Dallas. Together, they pursued the development of this very large surgical lung cancer center. Dr Shaw and his wife Ruth went to Afghanistan with Medico multiple times to teach men modern cardiac and thoracic surgery. They also served as consultants on Medico's Ship of Hope in Africa. Dr Shaw initiated multiple new operations including: 1) resection of Pancoast's cancer of the lung after preoperative irradiation; 2) upper lobe of the lung bronchoplasty, reattaching (and saving) the lower lobe to prevent the "disabling" pneumonectomy; and 3) resections of pulmonary mucoid impaction of the lung in asthmatics. Because of his humility and giving "the credit to others," Dr Shaw was never President of a major medical or surgical association. Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

A model for morbidity after lung resection in octogenarians.

PubMed

Berry, Mark F; Onaitis, Mark W; Tong, Betty C; Harpole, David H; D'Amico, Thomas A

2011-06-01

Age is an important risk factor for morbidity after lung resection. This study was performed to identify specific risk factors for complications after lung resection in octogenarians. A prospective database containing patients aged 80 years or older, who underwent lung resection at a single institution between January 2000 and June 2009, was reviewed. Preoperative, histopathologic, perioperative, and outcome variables were assessed. Morbidity was measured as a patient having any perioperative event as defined by the Society of Thoracic Surgeons General Thoracic Surgery Database. A multivariable risk model for morbidity was developed using a panel of established preoperative and operative variables. Survival was calculated using the Kaplan-Meier method. During the study period, 193 patients aged 80 years or older (median age 82 years) underwent lung resection: wedge resection in 77, segmentectomy in 13, lobectomy in 96, bilobectomy in four, and pneumonectomy in three. Resection was accomplished via thoracoscopy in 149 patients (77%). Operative mortality was 3.6% (seven patients) and morbidity was 46% (89 patients). A total of 181 (94%) patients were discharged directly home. Postoperative events included atrial arrhythmia in 38 patients (20%), prolonged air leak in 24 patients (12%), postoperative transfusion in 22 patients (11%), delirium in 16 patients (8%), need for bronchoscopy in 14 patients (7%), and pneumonia in 10 patients (5%). Significant predictors of morbidity by multivariable analysis included resection greater than wedge (odds ratio 2.98, p=0.006), thoracotomy as operative approach (odds ratio 2.6, p=0.03), and % predicted forced expiratory volume in 1s (odds ratio 1.28 for each 10% decrement, p=0.01). Octogenarians can undergo lung resection with low mortality. Extent of resection, use of a thoracotomy, and impaired lung function increase the risk of complications. Careful evaluation is necessary to select the most appropriate approach in octogenarians being considered for lung resection. Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Comparison of the outcomes of stereotactic body radiotherapy and surgery in elderly patients with cT1-2N0M0 non-small cell lung cancer.

PubMed

Nakagawa, Tatsuo; Negoro, Yoshiharu; Matsuoka, Tomoaki; Okumura, Norihito; Dodo, Yoshihiro

2014-07-01

This study aimed to compare the outcomes of stereotactic body radiotherapy (SBRT) and surgery in elderly patients with cT1-2N0M0 non-small cell lung cancer (NSCLC). Elderly patients (≥75 years) with cT1-2 (≤5 cm) N0M0 NSCLC who were treated with SBRT (n=35) or surgery (n=183) between January 2001 and December 2011 were analyzed. The following radiation doses were administered: 48 Gy/4-6 fractions in 12 patients; 50 Gy/4-5 fractions in 20; and 60 Gy/8 fractions in 3. The following surgical methods were performed: pneumonectomy in 2 patients, lobectomy in 154, segmentectomy in 23, and wedge resection in 4. Patients in the SBRT group had a higher mean age, a worse performance status, and a lower percentage of forced expiratory volume in 1.0 s than those in the surgery group. The overall 5-year survival rates were 43.8% and 67.6% for the SBRT and surgery groups, respectively (p=0.057, log-rank test). Regarding tumor diameter, patients in the surgery group survived significantly longer than did those in the SBRT group (>20-mm tumors, p=0.027; >30-mm tumors p=0.043), whereas survival did not differ significantly between the groups for ≤20-mm tumors (p=0.982). Multivariate analysis confirmed the improved survival in the surgery group compared to the SBRT group for all tumors (p=0.034) and for >20-mm tumors (p=0.016). Post-therapeutic survival among elderly patients might be better with surgery than with SBRT in NSCLC patients with tumors >20 mm. Copyright © 2014 The Japanese Respiratory Society. Published by Elsevier B.V. All rights reserved.

Fluoroscopic guidance for placing a double lumen endotracheal tube in adults.

PubMed

Calenda, Emile; Baste, Jean Marc; Hajjej, Ridha; Rezig, Najiba; Moriceau, Jerome; Diallo, Yaya; Sghaeir, Slim; Danielou, Eric; Peillon, Christophe

2014-09-01

The aim of this study was to assess the right placement of the double lumen endotracheal tube with fluoroscopic guidance, which is used in first intention prior to the fiberscope in our institution. This was a prospective observational study. The study was conducted in vascular and thoracic operating rooms. We enrolled 205 patients scheduled for thoracic surgery, with ASA physical statuses of I (n = 37), II (n = 84), III (n = 80), and IV (n = 4). Thoracic procedures were biopsy (n = 20), wedge (n = 34), culminectomy (n = 6), lobectomy (n = 82), pneumonectomy (n = 4), sympathectomy (n = 9), symphysis (n = 47), and thymectomy (n = 3). The intubation with a double lumen tube was performed with the help of a laryngoscope. Tracheal and bronchial balloons were inflated and auscultation was performed after right and left exclusions. One shot was performed to locate the position of the bronchial tube and the hook. Fluoroscopic guidance was used to relocate the tube in case of a wrong position. When the fluoroscopic guidance failed to position the tube, a fiberscope was used. Perioperative collapse of the lung was assessed by the surgeon during the surgery. Correct fluoroscopic image was obtained after the first attempt in 58.5% of patients therefore a misplaced position was encountered in 41.5%. The fluoroscopic guidance allowed an exact repositioning in 99.5% of cases, and the mean duration of the procedure was 8 minutes. A fiberscope was required to move the hook for one patient. We did not notice a moving of the double lumen endotracheal tube during the surgery. The surgeon satisfaction was 100%. The fluoroscopy evidenced the right position of the double lumen tube and allowed a right repositioning in 99.5% of patients with a very simple implementation. Copyright © 2014. Published by Elsevier B.V.

The N2 paradox: similar outcomes of pre- and postoperatively identified single-zone N2a positive non-small-cell lung cancer.

PubMed

Tsitsias, Thomas; Boulemden, Anas; Ang, Keng; Nakas, Apostolos; Waller, David A

2014-05-01

Resection of N2a non-small-cell lung cancer (NSCLC) diagnosed preoperatively is controversial but there is support for resection of unexpected N2 disease discovered at surgery. Since the seventh TNM edition, we have intentionally resected clinical N2a disease. To validate this policy, we determined prognostic factors associated with all resected N2 disease. From a prospective database of 1131 consecutive patients undergoing elective resection for primary lung cancer over a period of 8 years, we identified 68 patients (35 females (51.4%), mean age 66 years, standard deviation (SD) 9 years) who had pathological N2 disease. All patients had positron emission computed tomography (CT-PET) staging and selective mediastinoscopy. A Cox-regression analysis was performed to identify prognostic factors. At a median follow-up of 38.7 months (standard error 10, 95% confidence interval (CI) 19.0-58.4), the overall median survival was 22.2 months (95% CI 14.6-29.8) with 1-, 2- and 5-year survival rates of 63.3, 46.6 and 13.2%, respectively. Survival after resection of pN2 disease is adversely affected by the need for pneumonectomy, multizone pN2b involvement and by non-compliance with adjuvant chemotherapy. Pathological involvement of the subcarinal zone but no other zone appears to be associated with an adverse prognosis (hazard ratio (HR) 1.87, P = 0.063). Importantly, long-term survival is not different between those patients who have a negative preoperative PET-CT scan and yet are found to have pN2 after resection, and those who are single-zone cN2a positive before resection on PET-CT scan (HR 1.37, P = 0.335). Our results support a policy of intentionally resecting single-zone N2a NSCLC identified preoperatively as part of a multimodality therapy.

A prospective randomized trial comparing homologous and autologous fibrin sealants for the control of alveolar air leak.

PubMed

Kılıç, Burcu; Erşen, Ezel; Demirkaya, Ahmet; Kara, H Volkan; Alizade, Nurlan; İşcan, Mehlika; Kaynak, Kamil; Turna, Akif

2017-09-01

Postoperative air leak is a common complication seen after pulmonary resection. It is a significant reason of morbidity and also leads to greater hospital cost owing to prolonged length of stay. The purpose of this study is to compare homologous sealant with autologous one to prevent air leak following pulmonary resection. A total of 57 patients aged between 20 and 79 (mean age: 54.36) who underwent pulmonary resection other than pneumonectomy (lobar or sublobar resections) were analyzed. There were 47 males (83%) and 10 females (17%). Patients who intraoperatively had air leaks were randomized to receive homologous (Tisseel; n=28) or autologous (Vivostat; n=29) fibrin sealant. Differences among groups in terms of air leak, prolonged air leak, hospital stay, amount of air leak were analyzed. Indications for surgery were primary lung cancer in 42 patients (71.9%), secondary malignancy in 5 patients (8.8%), and benign disease in 10 patients (17.5%). Lobectomy was performed in 40 patients (70.2%), whereas 17 patients (29.8%) had wedge resection. Thirteen (46.4%) patients developed complications in patients receiving homologous sealant while 11 (38.0%) patients had complication in autologous sealant group (P=0.711). Median duration of air leak was 3 days in two groups. Time to intercostal drain removal was 3.39 and 3.38 days in homologous and autologous sealant group respectively (P=0.978). Mean hospital stay was 5.5 days in patients receiving homologous sealant whereas it was 5.0 days in patients who had autologous agent (P=0.140). There were no significant differences between groups in terms of measured maximum air leak (P=0.823) and mean air leak (P=0.186). There was no significant difference in the incidence of complications between two groups (P=0.711). Autologous and heterologous fibrin sealants are safe and acts similarly in terms of air leak and hospital stay in patients who had resectional surgery.

A prospective randomized trial comparing homologous and autologous fibrin sealants for the control of alveolar air leak

PubMed Central

Erşen, Ezel; Demirkaya, Ahmet; Kara, H. Volkan; Alizade, Nurlan; İşcan, Mehlika; Kaynak, Kamil; Turna, Akif

2017-01-01

Background Postoperative air leak is a common complication seen after pulmonary resection. It is a significant reason of morbidity and also leads to greater hospital cost owing to prolonged length of stay. The purpose of this study is to compare homologous sealant with autologous one to prevent air leak following pulmonary resection. Methods A total of 57 patients aged between 20 and 79 (mean age: 54.36) who underwent pulmonary resection other than pneumonectomy (lobar or sublobar resections) were analyzed. There were 47 males (83%) and 10 females (17%). Patients who intraoperatively had air leaks were randomized to receive homologous (Tisseel; n=28) or autologous (Vivostat; n=29) fibrin sealant. Differences among groups in terms of air leak, prolonged air leak, hospital stay, amount of air leak were analyzed. Results Indications for surgery were primary lung cancer in 42 patients (71.9%), secondary malignancy in 5 patients (8.8%), and benign disease in 10 patients (17.5%). Lobectomy was performed in 40 patients (70.2%), whereas 17 patients (29.8%) had wedge resection. Thirteen (46.4%) patients developed complications in patients receiving homologous sealant while 11 (38.0%) patients had complication in autologous sealant group (P=0.711). Median duration of air leak was 3 days in two groups. Time to intercostal drain removal was 3.39 and 3.38 days in homologous and autologous sealant group respectively (P=0.978). Mean hospital stay was 5.5 days in patients receiving homologous sealant whereas it was 5.0 days in patients who had autologous agent (P=0.140). There were no significant differences between groups in terms of measured maximum air leak (P=0.823) and mean air leak (P=0.186). There was no significant difference in the incidence of complications between two groups (P=0.711). Conclusions Autologous and heterologous fibrin sealants are safe and acts similarly in terms of air leak and hospital stay in patients who had resectional surgery. PMID:29221263

Surgeon's viewpoint on lung transplantation in cystic fibrosis patients - preliminary report.

PubMed

Kubisa, Bartosz; Piotrowska, Maria; Milczewska, Justyna; Bielewicz, Michał; Pieróg, Jarosław; Kozak, Anna; Czarnecka, Michalina; Wójcik, Norbert; Wasilewski, Piotr; Feledyk, Grzegorz; Kubisa, Anna; Brykczyński, Mirosław; Sielicki, Piotr; Grodzki, Tomasz

2015-01-01

The surgeon's viewpoint on a patient with cystic fibrosis differs from that of a pediatrician or internist. The problems a cystic fibrosis specialist encounters are different from those faced by the surgeon who takes over the patient in a very advanced, often terminal stage of the disease. Hence, the main problem for the surgeon is the decision concerning the surgery (lung transplantation, pneumonectomy, lobectomy). It is, therefore, important to lay down fundamental and appropriate rules concerning the indications and contraindications for lung transplantation, especially in patients with cystic fibrosis. The aim of this study was to analyze the methods of qualifying and preparing patients for surgery, as well as carrying out the procedure of transplantation and postoperative short and long-term care. The investigation was carried out on 16 patients with cystic fibrosis. Three were operated on and 10 were on the waiting list for transplantation. Two patients on the waiting list died, one patient was disqualified from transplantation. During qualification for lung transplantation, strict indications, contraindications and other factors (such as blood type, patient's height, coexisting complications) were taken under consideration. All the 3 patients after lung transplantation are alive and under our constant surveillance. Ten patients await transplantation, though four of them are suspended due to hepatitis C infection. Two patients on the waiting list died: one from respiratory insufficiency and the other in the course of bridge to-transplant veno-venous extracorporeal membrane oxygenation due to hepatic failure. One patient has been disqualified because of cachexia. Since lung transplantation is the final treatment of the end-stage pulmonary insufficiency in cystic fibrosis patients, the number of such procedures in cystic fibrosis is still too low in Poland. The fast development of these procedures is highly needed. It is necessary to develop better cooperation between different disciplines and specialists, especially between pediatricians and surgeons. The correct choice of the suitable moment for lung transplantation is crucial for the success of the procedure.

Multicentric analysis of performance after major lung resections by using the European Society Objective Score (ESOS).

PubMed

Brunelli, Alessandro; Varela, Gonzalo; Van Schil, Paul; Salati, Michele; Novoa, Nuria; Hendriks, Jeroen M; Jimenez, Marcelo F; Lauwers, Patrick

2008-02-01

Outcome endpoints are still the most widely used indicators of performance. However, they need to be risk-adjusted in order to be reliable instruments of audit. Recently, the European Society Objective Score (ESOS) was developed from the online European Thoracic Surgery Database as an audit tool. In this study, we applied for the first time the ESOS.01 to assess the performance of three European thoracic surgery units during three successive years of activity. This study is a retrospective analysis performed on prospective databases. We analysed 695 patients submitted to pneumonectomy (117) or lobectomy (578) for lung neoplasm at three European dedicated thoracic surgery units (unit A 264 patients, unit B 262, unit C 169) from January 2004 through December 2006. Qualified thoracic surgeons performed all the operations. No patients in this series were in the original ESOS development set. ESOS.01 was used to estimate the risk of in-hospital mortality in all patients. Observed and predicted mortality rates were then compared within each unit by the z-test. Cumulative observed mortality rates in units A, B and C were 2.3% (six cases), 2.7% (seven cases) and 4.1% (seven cases), respectively. We were not able to find statistically significant differences between observed and ESOS-predicted mortality rates. The comparison of risk-adjusted mortality rates between units did not show significant differences (unit A 3.9%, unit B 3.3%, unit C 5.6%). The use of ESOS.01 revealed that the performances of all units were in line with the predicted ones during each period under analysis and did not differ between each other. The results of our study warrant future efforts to refine the ESOS model and to develop other risk-adjusted outcome indicators with the aim to establish European benchmarks of performance.

Prognostic factors for cases with no extracranial metastasis in whom brain metastasis is detected after resection of non-small cell lung cancer.

PubMed

Bae, Mi Kyung; Yu, Woo Sik; Byun, Go Eun; Lee, Chang Young; Lee, Jin Gu; Kim, Dae Joon; Chung, Kyung Young

2015-05-01

This study aimed to determine prognostic factors associated with postrecurrence survival in cases with postoperative brain metastasis but with no extracranial metastasis in non-small cell lung cancer (NSCLC). Between 1992 and 2012, a total of 2832 patients underwent surgical resection for NSCLC. Among those, 86 patients had postoperative brain metastasis as the initial recurrence. Those patients were retrospectively reviewed. The median follow-up time after the initial lung resection was 24.0 months (range, 2.0-126.0 months). The median overall survival after initial lung cancer resection was 25.0 months and the median overall postrecurrence survival was 11 months. An initial lesion of adenocarcinoma (hazard ratio, 0.548; 95% confidence interval, 0.318 to 0.946; p=0.031), non-pneumonectomy, and a disease-free interval longer than 10.0 months (hazard ratio, 0.565; 95% confidence interval, 0.321-0.995; p=0.048) from the initial lung resection to the diagnosis of brain metastasis positively related to a good postrecurrence survival. Solitary brain metastasis and a size of less than 3 cm for the largest brain lesion were also positive factors for postrecurrence survival. Systemic chemotherapy for brain metastasis (hazard ratio, 0.356; 95% confidence interval, 0.189-0.670; p=0.001) and local treatment of surgery and/or stereotactic radiosurgery (SRS) for brain lesions (hazard ratio, 0.321; 95% confidence interval, 0.138-0.747; p=0.008) were positive factors for better postrecurrence survival. In patients with brain metastasis after resection for NSCLC with no extracranial metastasis, adenocarcinoma histologic type, longer disease-free interval, systemic chemotherapy for brain metastasis and local treatment of surgery and/or SRS for brain metastasis are independent positive prognostic factors for postrecurrence survival. Copyright © 2015. Published by Elsevier Ireland Ltd.

Age-Dependent Decline in Mouse Lung Regeneration with Loss of Lung Fibroblast Clonogenicity and Increased Myofibroblastic Differentiation

PubMed Central

Paxson, Julia A.; Gruntman, Alisha; Parkin, Christopher D.; Mazan, Melissa R.; Davis, Airiel; Ingenito, Edward P.; Hoffman, Andrew M.

2011-01-01

While aging leads to a reduction in the capacity for regeneration after pneumonectomy (PNX) in most mammals, this biological phenomenon has not been characterized over the lifetime of mice. We measured the age-specific (3, 9, 24 month) effects of PNX on physiology, morphometry, cell proliferation and apoptosis, global gene expression, and lung fibroblast phenotype and clonogenicity in female C57BL6 mice. The data show that only 3 month old mice were fully capable of restoring lung volumes by day 7 and total alveolar surface area by 21 days. By 9 months, the rate of regeneration was slower (with incomplete regeneration by 21 days), and by 24 months there was no regrowth 21 days post-PNX. The early decline in regeneration rate was not associated with changes in alveolar epithelial cell type II (AECII) proliferation or apoptosis rate. However, significant apoptosis and lack of cell proliferation was evident after PNX in both total cells and AECII cells in 24 mo mice. Analysis of gene expression at several time points (1, 3 and 7 days) post-PNX in 9 versus 3 month mice was consistent with a myofibroblast signature (increased Tnc, Lox1, Col3A1, Eln and Tnfrsf12a) and more alpha smooth muscle actin (αSMA) positive myofibroblasts were present after PNX in 9 month than 3 month mice. Isolated lung fibroblasts showed a significant age-dependent loss of clonogenicity. Moreover, lung fibroblasts isolated from 9 and 17 month mice exhibited higher αSMA, Col3A1, Fn1 and S100A expression, and lower expression of the survival gene Mdk consistent with terminal differentiation. These data show that concomitant loss of clonogenicity and progressive myofibroblastic differentiation contributes to the age-dependent decline in the rate of lung regeneration. PMID:21912590

Geographic and socioeconomic factors in patients with malignant pleural mesothelioma in New South Wales and their impact upon clinical outcomes.

PubMed

Linton, Anthony; Soeberg, Matthew; Broome, Richard; Kao, Steven; van Zandwijk, Nico

2017-07-01

Whilst the impact of clinicopathological factors on the prognosis of malignant pleural mesothelioma (MPM) is well understood, socioeconomic and geographic factors have received less attention. We analysed the relationship between geographic and socioeconomic factors upon survival and treatment provision in a large series of patients with MPM. We assessed MPM patients awarded compensation between 2002 and 2009 with additional MPM incidence data from the New South Wales (NSW) Cancer Registry. The impact of geographic remoteness, distance from oncological multidisciplinary team (MDT) and Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD) upon survival, clinical features and treatment received was analysed. We identified 910 patients (67% residing in major cities; 92% <50 km from MDT). Median overall survival was 10.0 months. On multivariate analysis, age >70 (hazard ratio (HR) = 1.39), male gender (HR =1.36), non-epithelioid histological subtype (HR = 2.18) and IRSAD status by decreasing quintile (HR = 1.06) were independent prognostic factors. There was no significant advantage for patients residing in major cities (10.6 months vs 8.8 months; P = 0.162) or within 50 km of MDT (10.3 months vs 7.8 months; P = 0.539). Patient's geographic location and distance to MDT did not impact chemotherapy, adjuvant radiotherapy or extrapleural pneumonectomy provision. Socioeconomically disadvantaged patients were significantly less likely to receive chemotherapy (37.4% vs 54.8%; P = 0.001). This study provides evidence for differences in the treatment and survival according to socioeconomic status for compensated MPM patients in NSW. Further research is warranted to seek additional explanations for the differences noted by comparing the treatments and outcomes of compensated and non-compensated MPM patients in NSW. © 2017 Asian Pacific Society of Respirology.

The Society of Thoracic Surgeons General Thoracic Surgery Database: establishing generalizability to national lung cancer resection outcomes.

PubMed

LaPar, Damien J; Bhamidipati, Castigliano M; Lau, Christine L; Jones, David R; Kozower, Benjamin D

2012-07-01

The Society of Thoracic Surgeons General Thoracic Surgery Database (GTDB) has demonstrated outstanding results for lung cancer resection. However, whether the GTDB results are generalizable nationwide is unknown. The purpose of this study was to establish the generalizability of the GTDB by comparing lung cancer resection results with those of the Nationwide Inpatient Sample (NIS), the largest all-payer inpatient database in the United States. From 2002 to 2008, primary lung cancer resection outcomes were compared between the GTDB (n = 19,903) and the NIS (n = 246,469). Primary outcomes were the proportion of procedures performed nationally that were captured in the GTDB and differences in mortality rates and hospital length of stay. Observed differences in patient characteristics, operative procedures, and postoperative events were also analyzed. Annual GTDB lung cancer resection volume has increased over time but only captures an estimated 8% of resections performed nationally. The GTDB and NIS databases had similar median patient age (67 vs 68 years) and female sex (50% vs 49%), lobectomy was the most common procedure (64.7% vs 79.7%; p < 0.001), and pneumonectomies were uncommon (6.3% vs 7.2%; p < 0.001). Compared with NIS, the GTDB had significantly lower unadjusted discharge mortality rates (1.8% vs 3.0%), median length of stay (5.0 vs 7.0 days; p < 0.001), and postoperative pulmonary complication rates (18.5% vs 23.6%, p < 0.001). The GTDB represents a small percentage of the lung cancer resections performed nationally and reports significantly lower mortality rates and shorter hospital length of stay than national results. The GTDB is not broadly generalizable. These results establish a benchmark for future GTDB comparisons and highlight the importance of increasing participation in the database. Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

The Relationship between Case-Volume, Care Quality, and Outcomes of Complex Cancer Surgery

PubMed Central

Auerbach, Andrew D; Maselli, Judith; Carter, Jonathan; Pekow, Penelope S; Lindenauer, Peter K

2010-01-01

Background How case volume and quality of care relate to each other and to results of complex cancer surgery is not well understood. Study Design Observational cohort of 14,170 patients 18 or older who underwent pneumonectomy, esophagectomy, pancreatectomy, or pelvic surgery for cancer between 10/1/2003 and 9/1/2005 at a United States hospital participating in a large benchmarking database. Case volumes were estimated within our dataset. Quality was measured by determining whether ideal patients did not receive appropriate perioperative medications (such as antibiotics to prevent surgical site infections) both as individual ‘missed’ measures, as well as the overall number missed. We used hierarchical models to estimate effects of volume and quality on 30-day readmission, in-hospital mortality, length of stay, and costs. Results After adjustment, we noted no consistent associations between higher hospital or surgeon volume and mortality, readmission, length of stay, or costs. Adherence to individual measures was not consistently associated with improvement in readmission, mortality, or other outcomes. For example, continuing antimicrobials past 24 hours was associated with longer length of stay (21.5% higher, 95% CI 19.5% to 23.6%) and higher costs (17% higher, 95% CI 16% to 19%). In contrast, overall adherence, while not not associated with differences in mortality or readmission, was consistently associated with longer length of stay (7.4% longer with one missed measure and 16.4% longer with 2 or more) and higher costs (5% higher with one missed measure, and 11% higher with 2 or more). Conclusions While hospital and surgeon volume were not associated with outcomes, lower overall adherence to quality measures is associated with higher costs, but not improved outcomes. This finding may provide a rationale for improving care systems by maximizing care consistency, even if outcomes are not affected. PMID:20829079

Is there a role for pre-operative contrast-enhanced magnetic resonance imaging for radical surgery in malignant pleural mesothelioma?

PubMed

Stewart, Duncan; Waller, David; Edwards, John; Jeyapalan, Kanagaratnam; Entwisle, James

2003-12-01

To assess the use of contrast-enhanced magnetic resonance imaging (CEMRI) in addition to computed tomography in the pre-operative assessment of patients for radical surgery in malignant pleural mesothelioma. Over a 45-month period, 51 of 76 patients assessed (69 men and seven women), underwent extra-pleural pneumonectomy or radical pleurectomy/decortication. Post-operative pathological stage was correlated with radiological staging, with particular emphasis on tumour resectability. Seventeen (22%) patients were found on CEMRI to have unresectable, but histologically unconfirmed disease, not previously seen on CT. Fifty-one (67%) patients proceeded to radical surgery, but pathological nodal data were incomplete in three, so excluding these patients from further analyses. The median pre-operative interval after CEMRI was 17 days. Two patients were found to have unexpectedly extensive disease at thoracotomy, thus the sensitivity of CEMRI for prediction of resectability was 97%. Using the International Mesothelioma Interest Group system, tumour stage was correctly predicted by CEMRI in 48% of patients, but understaged in 50% of cases, largely due to the underestimation of pericardial involvement, but this did not affect resectability and had no significant effect on prognosis. Nodal stage was correctly identified in 60% of patients. CEMRI was successful in predicting pathological tumour stage T3 or less (sensitivity of 85%; specificity of 100%), but less so in identifying tumour stage T2 or less (sensitivity of 23%; specificity of 96%) or N2 nodal disease (sensitivity 66%; specificity 73%). CEMRI is most useful in the differentiation of T3 and T4 disease and may be unnecessary at earlier stages. Its multiplanar tumour localisation abilities are of value in the assessment of resectability. It is unlikely to contribute significantly to nodal staging, but it remains a valuable adjunct in the selection of patients for radical surgery.

Identifying areas of weakness in thoracic surgery residency training: a comparison of the perceptions of residents and program directors.

PubMed

Edwards, Janet P; Schofield, Adam; Paolucci, Elizabeth Oddone; Schieman, Colin; Kelly, Elizabeth; Servatyari, Ramin; Dixon, Elijah; Ball, Chad G; Grondin, Sean C

2014-01-01

To identify core thoracic surgery procedures that require increased emphasis during thoracic surgery residency for residents to achieve operative independence and to compare the perspectives of residents and program directors in this regard. A modified Delphi process was used to create a survey that was distributed electronically to all Canadian thoracic surgery residents (12) and program directors (8) addressing the residents' ability to perform 19 core thoracic surgery procedures independently after the completion of residency. Residents were also questioned about the adequacy of their operative exposure to these 19 procedures during their residency training. A descriptive summary including calculations of frequencies and proportions was conducted. The perceptions of the 2 groups were then compared using the Fisher exact test employing a Bonferroni correction. The relationship between residents' operative exposure and their perceived operative ability was explored in the same fashion. The response rate was 100% for residents and program directors. No statistical differences were found between residents' and program directors' perceptions of residents' ability to perform the 19 core procedures independently. Both groups identified lung transplantation, first rib resection, and extrapleural pneumonectomy as procedures for which residents were not adequately prepared to perform independently. Residents' subjective ratings of operative exposure were in good agreement with their reported operative ability for 13 of 19 procedures. This study provides new insight into the perceptions of thoracic surgery residents and their program directors regarding operative ability. This study points to good agreement between residents and program directors regarding residents' surgical capabilities. This study provides information regarding potential weaknesses in thoracic surgery training, which may warrant an examination of the curricula of existing programs as well as a reconsideration of what the scope of practice of a general thoracic surgeon should entail. © 2013 Published by Association of Program Directors in Surgery on behalf of Association of Program Directors in Surgery.

Anaesthesia in Chest Surgery, with Special Reference to Controlled Respiration and Cyclopropane: (Section of Anaesthetics).

PubMed

Nosworthy, M D

1941-06-01

Problems in chest surgery: Cases with prolonged toxaemia or amyloid disease require an anaesthetic agent of low toxicity. When sputum or blood are present in the tracheobronchial tree the anaesthesia should abolish reflex distrubances and excessive sputum be removed by suction. The technique should permit the use of a high oxygen atmosphere; controlled respiration with cyclopropane or ether fulfil these requirements. Open pneumothorax is present when a wound of the chest wall allows air to pass in and out of the pleural cavity. The lung on the affected side collapses and the mediastinum moves over and partly compresses the other lung.The dangers of an open pneumothorax: (1) Paradoxical respiration-the lung on the affected side partially inflates on expiration and collapses on inspiration. Part of the air entering the good lung has been shuttled back from the lung on the affected side and is therefore vitiated. Full expansion of the sound lung is handicapped by the initial displacement of the mediastinum which increases on inspiration. The circulation becomes embarrassed.(2) Vicious circle coughing. During a paroxysm of coughing dyspnoea will occur. This accentuates paradoxical respiration and starts a vicious circle. Death from asphyxia may result.Special duties of the anaesthetist: (1) To carry out or supervise continuous circulatory resuscitation. During a thoracotomy a drip blood transfusion maintains normal blood-pressure and pulse-rate.(2) To maintain effcient respiration.Positive pressure anaesthesia: Risk of impacting secretions in smaller bronchi with subsequent atelectasis; eventual risk of CO(2) poisoning without premonitory signs.Controlled respiration: (1) How it is produced. (2) Its uses in chest surgery.Controlled respiration means that the anaesthetist, having abolished the active respiratory efforts of the patient, maintains an efficient tidal exchange by rhythmic squeezing of the breathing bag. This may be done mechanically by Crafoord's modification of Frenkner's spiropulsator or by hand.Active respiration will cease (i) if the patient's CO(2) is lowered sufficiently by hyperventilation, (ii) if the patient's respiratory centre is depressed sufficiently by sedative and anaesthetic drugs, and (iii) by a combination of (i) and (ii) of less degree.The author uses the second method, depressing the respiratory centre with omnoponscopolamine, pentothal sodium, and then cyclopropane. The CO(2) absorption method is essential for this technique, and this and controlled respiration should be mastered by the anaesthetist with a familiar agent and used at first only in uncomplicated cases.The significance of cardiac arrhythmias occuring with cyclopropane is discussed.The place of the other available anaesthetic agents is discussed particularly on the advisability of using local anaesthesia for the drainage of empyema or lung abscess.Pharyngeal airway or endotracheal tube? Anaesthesia may be maintained with a pharyngeal airway in many cases but intubation must be used when tracheobronchial suction may be necessary and when there may be difficulty in maintaining an unobstructed airway.A one-lung anaesthesia is ideal for pneumonectomy. This may be obtained by endotracheal anaesthesia after bronchial tamponage of the affected side (Crafoord, v. fig. 6b) or by an endobronchial intubation of the sound side (v. figs. 9b and 9c). Endobronchial placing of the breathing tube may be performed "blind". Before deciding on blind bronchial intubation, the anaesthetist must examine X-ray films for any abnormality deviating the trachea or bronchi. Though the right bronchus may be easily intubated blindly as a rule, there is the risk of occluding the orifice of the upper lobe bronchus (fig. 9d) when the patient will become cyanosed. If the tube bevel is facing its orifice the risk of occlusion will be decreased (fig. 9c).Greater accuracy in placing the tube can be effected by inserting it under direct vision. Instruments for performing this manoeuvre are described.In lobectomy for bronchiectasis the anaesthetist must try to prevent the spread of infection to other parts. Ideally, the bronchus of the affected lobe should be plugged with ribbon gauze (Crafoord, v. fig. 6c) or a suction catheter with a baby balloon on it placed in the affected bronchus. In the presence of a large bronchopleural fistula controlled respiration cannot be established during operation. As the surgeon is rarely able to plug the fistula, if pneumonectomy is to be performed intubation for a one-lung anaesthesia is the best method. During other procedures it is essential to maintain quiet respiration.In war casualties it is almost always possible, with the technique described, to leave the lung on the affected side fully expanded and thus frequently to restore normal respiratory physiology. Co-operation between surgeon and anaesthetist is essential.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Chance, William W.; Rice, David C.; Allen, Pamela K.

Purpose: To investigate safety, efficacy, and recurrence after hemithoracic intensity modulated radiation therapy after pleurectomy/decortication (PD-IMRT) and after extrapleural pneumonectomy (EPP-IMRT). Methods and Materials: In 2009-2013, 24 patients with mesothelioma underwent PD-IMRT to the involved hemithorax to a dose of 45 Gy, with an optional integrated boost; 22 also received chemotherapy. Toxicity was scored with the Common Terminology Criteria for Adverse Events v4.0. Pulmonary function was compared at baseline, after surgery, and after IMRT. Kaplan-Meier analysis was used to calculate overall survival (OS), progression-free survival (PFS), time to locoregional failure, and time to distant metastasis. Failures were in-field, marginal, or outmore » of field. Outcomes were compared with those of 24 patients, matched for age, nodal status, performance status, and chemotherapy, who had received EPP-IMRT. Results: Median follow-up time was 12.2 months. Grade 3 toxicity rates were 8% skin and 8% pulmonary. Pulmonary function declined from baseline to after surgery (by 21% for forced vital capacity, 16% for forced expiratory volume in 1 second, and 19% for lung diffusion of carbon monoxide [P for all = .01]) and declined still further after IMRT (by 31% for forced vital capacity [P=.02], 25% for forced expiratory volume in 1 second [P=.01], and 30% for lung diffusion of carbon monoxide [P=.01]). The OS and PFS rates were 76% and 67%, respectively, at 1 year and 56% and 34% at 2 years. Median OS (28.4 vs 14.2 months, P=.04) and median PFS (16.4 vs 8.2 months, P=.01) favored PD-IMRT versus EPP-IMRT. No differences were found in grade 4-5 toxicity (0 of 24 vs 3 of 24, P=.23), median time to locoregional failure (18.7 months vs not reached, P not calculable), or median time to distant metastasis (18.8 vs 11.8 months, P=.12). Conclusions: Hemithoracic intensity modulated radiation therapy after pleurectomy/decortication produced little high-grade toxicity but led to progressive declines in pulmonary function; OS and PFS were better in PD-IMRT compared with EPP-IMRT.« less

Long-term survival of 42 patients with resected N2 non-small-cell lung cancer: the impact of 2-(18)F-fluoro-2-deoxy-D-glucose positron emission tomogram mediastinal staging.

PubMed

Barnett, Stephen; Baste, Jean-Marc; Murugappan, Kowsi; Tog, Check; Berlangieri, Salvatore; Scott, Andrew; Seevanayagam, Siven; Knight, Simon

2011-01-01

Prognostic information known preoperatively allows stratification of patients to surgery; induction therapy and surgery; or definitive chemoradiotherapy and may prevent a futile thoracotomy. Attention has focussed on the standard uptake value (SUV) of the primary tumour but less has been described regarding the 18F-fluoro-2-deoxy-D-glucose (18F-FDG) avidity of mediastinal nodes. We aimed, in a group of surgically resected cN0-1 but pN2 tumours, to compare the survival of patients with and without 18F-FDG avid mediastinal nodes. Retrospective review of a surgical database identified cN0-1 non-small-cell lung cancer (NSCLC) patients with pN2 disease after resection. Survival of non-FDG avid N2 versus FDG avid N2 groups was compared after stratification according to variables found on univariate analysis to affect survival. From January 1993 to December 2006, 42 patients were identified; 27 (64%) had non-FDG avid N2 disease. Five-year and median survival were better in the non-FDG avid N2 disease group, 25% versus 0% and 30 (16-44) versus 13 (10-16) months, respectively (p=0.02). After 1998, the difference in survival was 41% versus 0% and 35 (14-56) versus 12 (16-18) months, respectively (p=0.02). After resection, patients with non-FDG avid N2 disease have better survival than patients with FDG avid N2 disease. Exploratory thoracotomy alone (after frozen section analysis) cannot be advocated in patients with non-FDG avid N2 disease as survival after resection appears at least equivalent to alternate therapeutic approaches in this group. This assertion may be tempered if right pneumonectomy is required or R0 resection is unachievable. Mediastinal nodal avidity may improve stratification in future studies of long-term survival in NSCLC. Crown Copyright © 2010. Published by Elsevier B.V. All rights reserved.

In patients with a tumour invading the phrenic nerve does prophylactic diaphragm plication improve postoperative lung function?

PubMed

Beattie, Gwyn W; Dunn, William G; Asif, Mohammed

2016-09-01

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'In patients with tumours involving the phrenic nerve, does prophylactic diaphragm plication improve lung function following tumour resection?' Using the reported search, 258 papers were found of which 6 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Three case reports and one case series represent 37 patients in the literature along with two relevant animal studies. Patients treated with prophylactic plication at the time of injury or sacrifice of the phrenic nerve had reduced radiological evidence of diaphragm paralysis, lower reported shortness of breath and reduced requirement for ventilatory support. In patients with prophylactic diaphragm plication and a concurrent pulmonary resection, the predicted postoperative lung function correlated closely with the postoperative measured FEV1, FVC and gas transfer. The postoperative measured FEV1 was reported as 86-98%, the FVC 82-89% and gas transfer 97% of the predicted values. Two animal models investigate the mechanics of respiration, spirometry and gas exchange following diaphragmatic plication. A randomized control study in four dogs measured a 50% reduction in tidal volume and respiratory rate, a 40% decrease in arterial PO2 and a 43% increase in arterial CO2 when the phrenic nerve was crushed in animals with a pneumonectomy but without prophylactic diaphragm plication. A further randomized control animal study with 28 dogs found that plicating the diaphragm after unilateral phrenic nerve transection resulted in a significant increase in tidal volume and lung compliance and a significant decrease in respiratory frequency and the work of breathing. Prophylactic diaphragm plication may preserve lung function, reduce the risk of ventilator dependence and improve the mechanics of breathing in patients with phrenic nerve transection. If transection of the phrenic nerve occurs, and it is recognized intraoperatively, prophylactic diaphragm plication should be considered. © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

A glance at the history of uniportal video-assisted thoracic surgery.

PubMed

Mineo, Tommaso Claudio; Ambrogi, Vincenzo

2017-01-01

In the history of thoracic surgery, the advent of video-assisted thoracic surgery (VATS) had on effect equivalent to that provoked by a true revolution. VATS successfully allowed minor, major and complex procedures for various lung and mediastinal pathologies with small incision instead of the traditional accesses. These small incisions abolished ugly scars, generated less acute and chronic pain, reduced hospital stay and costs, allowed faster return to normal day life activities. Conventional VATS was initially performed through 3-4 ports and rapidly evolved to uniportal or single portal access [uniportal video-assisted thoracic surgery (uniVATS)]. First uniportal procedures were published in 2000. In 2010, uniportal technique for lobectomy was described. Focused experimental courses, live surgery events, the internet media favored the rapid diffusion of this technique over the world. Major and complex uniVATS lung resections involving segmentectomy, pneumonectomy, bronchoplasty and vascular reconstruction, redo VATS, en bloc chest wall resections have been accomplished with satisfactory outcomes. Interestingly, different uniportal approaches and techniques are emerging from a number of VATS centers particularly experienced in the mini-invasive thoracic surgery. As confidence grew, in 2014, the first uniVATS left upper lobectomy via the subxiphoid approach was reported. This novel technique is quite challenging but appropriate patient selection as well as availability of dedicated instruments allowed to perform procedures safely. The diffusion of uniVATS paralleled with the development of nonintubated awake anesthesia technique. In 2007 the first nonintubated lobectomy was described. In 2014 the first single port VATS lobectomy in a nonintubated patient with lung cancer of the right middle lobe was accomplished. The nonintubated uniVATS represents an intriguing technique, so that very experienced thoracoscopic surgeons may enroll to surgery elderly and high risk patients. Decreased postoperative pain and hospitalization, faster access to the radio-chemotherapy and diminished inflammatory response are important benefits of the modern approach to the thoracic pathologies. The history of uniVATS documented a constant and irresistible progress. This technique may further provide unthinkable surprises in next future.

Effects of extended pleurectomy and decortication on quality of life and pulmonary function in patients with malignant pleural mesothelioma.

PubMed

Burkholder, David; Hadi, Duraid; Kunnavakkam, Rangesh; Kindler, Hedy; Todd, Kristy; Celauro, Amy Durkin; Vigneswaran, Wickii T

2015-05-01

Maximal cytoreductive surgeries--extrapleural pneumonectomy and extended pleurectomy and decortication (EPD)--are effective surgical treatments in selected patients with malignant pleural mesothelioma. Extended pleurectomy and decortication results in equivalent survival yet better health-related quality of life (HRQoL). Patients with malignant pleural mesothelioma were studied for the effects of EPD on HRQoL and pulmonary function. The European Organization for Research and Treatment of Cancer Core Quality of Life Questionaire-C30 was used to evaluate HRQoL before operation, and at 4 to 5 and 7 to 8 months postoperatively. Pulmonary function tests were measured immediately before and 5 to 7 months after the operation. Patients were compared according to World Health Organization baseline performance status (PS). Of the 36 patients enrolled, 17 were PS 0 and 19 were PS 1 or PS 2 at baseline. Patients in groups PS 1 and PS 2 had significantly worse global health, functional, and symptoms scores. After EPD, PS 0 patients had no change in global health or function and symptoms scores except for emotional function, whereas PS 1 or PS 2 patients showed improvements at 4 to 5 months with further improvements at 7 to 8 months. The PS 0 patients demonstrated a significant decrease in forced vital capacity (p = 0.001), forced expiratory volume in 1 second (p = 0.002), total lung capacity (p = 0.0006) and diffusing capacity of the lung for carbon monoxide (p = 0.003) after EPD, whereas no change was observed in PS 1 and PS 2 patients. Extended pleurectomy and decortication did not improve overall HRQoL and had a negative impact in pulmonary function in minimally symptomatic patients. In symptomatic patients, a significant improvement in HRQoL was observed after EPD, which continued at late follow-up, although the pulmonary function was not affected. As changes in HRQoL are multidimensional, the preservation of the pulmonary function may have contributed to the net benefit observed in PS 1 and PS 2 patients. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Ratio between maximum standardized uptake value of N1 lymph nodes and tumor predicts N2 disease in patients with non-small cell lung cancer in 18F-FDG PET-CT scan.

PubMed

Honguero Martínez, A F; García Jiménez, M D; García Vicente, A; López-Torres Hidalgo, J; Colon, M J; van Gómez López, O; Soriano Castrejón, Á M; León Atance, P

2016-01-01

F-18 fluorodeoxyglucose integrated PET-CT scan is commonly used in the work-up of lung cancer to improve preoperative disease stage. The aim of the study was to analyze the ratio between SUVmax of N1 lymph nodes and primary lung cancer to establish prediction of mediastinal disease (N2) in patients operated on non-small cell lung cancer. This is a retrospective study of a prospective database. Patients operated on non-small cell lung cancer (NSCLC) with N1 disease by PET-CT scan were included. None of them had previous induction treatment, but they underwent standard surgical resection plus systematic lymphadenectomy. There were 51 patients with FDG-PET-CT scan N1 disease. 44 (86.3%) patients were male with a mean age of 64.1±10.8 years. Type of resection: pneumonectomy=4 (7.9%), lobectomy/bilobectomy=44 (86.2%), segmentectomy=3 (5.9%). adenocarcinoma=26 (51.0%), squamous=23 (45.1%), adenosquamous=2 (3.9%). Lymph nodes after surgical resection: N0=21 (41.2%), N1=12 (23.5%), N2=18 (35.3%). Mean ratio of the SUVmax of N1 lymph node to the SUVmax of the primary lung tumor (SUVmax N1/T ratio) was 0.60 (range 0.08-2.80). ROC curve analysis to obtain the optimal cut-off value of SUVmax N1/T ratio to predict N2 disease was performed. At multivariate analysis, we found that a ratio of 0.46 or greater was an independent predictor factor of N2 mediastinal lymph node metastases with a sensitivity and specificity of 77.8% and 69.7%, respectively. SUVmax N1/T ratio in NSCLC patients correlates with mediastinal lymph node metastasis (N2 disease) after surgical resection. When SUVmax N1/T ratio on integrated PET-CT scan is equal or superior to 0.46, special attention should be paid on higher probability of N2 disease. Copyright © 2015 Elsevier España, S.L.U. and SEMNIM. All rights reserved.

Hemithoracic intensity modulated radiation therapy after pleurectomy/decortication for malignant pleural mesothelioma: toxicity, patterns of failure, and a matched survival analysis.

PubMed

Chance, William W; Rice, David C; Allen, Pamela K; Tsao, Anne S; Fontanilla, Hiral P; Liao, Zhongxing; Chang, Joe Y; Tang, Chad; Pan, Hubert Y; Welsh, James W; Mehran, Reza J; Gomez, Daniel R

2015-01-01

To investigate safety, efficacy, and recurrence after hemithoracic intensity modulated radiation therapy after pleurectomy/decortication (PD-IMRT) and after extrapleural pneumonectomy (EPP-IMRT). In 2009-2013, 24 patients with mesothelioma underwent PD-IMRT to the involved hemithorax to a dose of 45 Gy, with an optional integrated boost; 22 also received chemotherapy. Toxicity was scored with the Common Terminology Criteria for Adverse Events v4.0. Pulmonary function was compared at baseline, after surgery, and after IMRT. Kaplan-Meier analysis was used to calculate overall survival (OS), progression-free survival (PFS), time to locoregional failure, and time to distant metastasis. Failures were in-field, marginal, or out of field. Outcomes were compared with those of 24 patients, matched for age, nodal status, performance status, and chemotherapy, who had received EPP-IMRT. Median follow-up time was 12.2 months. Grade 3 toxicity rates were 8% skin and 8% pulmonary. Pulmonary function declined from baseline to after surgery (by 21% for forced vital capacity, 16% for forced expiratory volume in 1 second, and 19% for lung diffusion of carbon monoxide [P for all = .01]) and declined still further after IMRT (by 31% for forced vital capacity [P=.02], 25% for forced expiratory volume in 1 second [P=.01], and 30% for lung diffusion of carbon monoxide [P=.01]). The OS and PFS rates were 76% and 67%, respectively, at 1 year and 56% and 34% at 2 years. Median OS (28.4 vs 14.2 months, P=.04) and median PFS (16.4 vs 8.2 months, P=.01) favored PD-IMRT versus EPP-IMRT. No differences were found in grade 4-5 toxicity (0 of 24 vs 3 of 24, P=.23), median time to locoregional failure (18.7 months vs not reached, P not calculable), or median time to distant metastasis (18.8 vs 11.8 months, P=.12). Hemithoracic intensity modulated radiation therapy after pleurectomy/decortication produced little high-grade toxicity but led to progressive declines in pulmonary function; OS and PFS were better in PD-IMRT compared with EPP-IMRT. Copyright © 2015 Elsevier Inc. All rights reserved.

Short-term outcomes of cadaveric lung transplantation in ventilator-dependent patients

PubMed Central

2009-01-01

Introduction Survival after cadaveric lung transplantation (LTx) in respiratory failure recipients who were already dependent on ventilation support prior to transplantation is poor, with a relatively high rate of surgical mortality and morbidity. In this study, we sought to describe the short-term outcomes of bilateral sequential LTx (BSLTx) under extracorporeal membrane oxygenation (ECMO) support in a consecutive series of preoperative respiratory failure patients. Methods Between July 2006 and July 2008, we performed BSLTx under venoarterious (VA) ECMO support in 10 respiratory failure patients with various lung diseases. Prior to transplantation, 6 patients depended on invasive mechanical ventilation support and the others (40%) needed noninvasive positive pressure ventilation to maintain adequate gas exchange. Their mean age was 40.9 years and the mean observation period was 16.4 months. Results Except for 1 ECMO circuit that had been set up in the intensive care unit for pulmonary crisis 5 days prior to transplantation, most ECMO (90%) circuits were set up in the operating theater prior to pneumonectomy of native lung during transplantation. Patients were successfully weaned off ECMO circuits immediately after transplantation in 8 cases, and within 1 day (1/10 patients) and after 9 days (1/10 patients) due to severe reperfusion lung edema following transplantation. The mean duration of ECMO support in those successfully weaned off in the operating theater (n = 8) was 7.8 hours. The average duration of intensive care unit stay (n = 10) was 43.1 days (range, 35 to 162 days) and hospital stay (n = 10) was 70 days (range, 20 to 86 days). Although 4 patients (40%) had different degrees of complicated postoperative courses unrelated to ECMO, all patients were discharged home postoperatively. The mean forced vital capacity and the forced expiratory volume in 1 second both increased significantly postoperatively. The cumulative survival rates at 3 months and at 12 months post-transplantation were 100% and 90%. Conclusions Although BSLTx in this critical population has varied surgical complications and prolonged length of postoperative ICU and hospital stays, all the patients observed in this study could tolerate the transplant procedures under VA ECMO support with promising pulmonary function and satisfactory short-term outcome. PMID:19660110

A risk score to predict the incidence of prolonged air leak after video-assisted thoracoscopic lobectomy: An analysis from the European Society of Thoracic Surgeons database.

PubMed

Pompili, Cecilia; Falcoz, Pierre Emmanuel; Salati, Michele; Szanto, Zalan; Brunelli, Alessandro

2017-04-01

The study objective was to develop an aggregate risk score for predicting the occurrence of prolonged air leak after video-assisted thoracoscopic lobectomy from patients registered in the European Society of Thoracic Surgeons database. A total of 5069 patients who underwent video-assisted thoracoscopic lobectomy (July 2007 to August 2015) were analyzed. Exclusion criteria included sublobar resections or pneumonectomies, lung resection associated with chest wall or diaphragm resections, sleeve resections, and need for postoperative assisted mechanical ventilation. Prolonged air leak was defined as an air leak more than 5 days. Several baseline and surgical variables were tested for a possible association with prolonged air leak using univariable and logistic regression analyses, determined by bootstrap resampling. Predictors were proportionally weighed according to their regression estimates (assigning 1 point to the smallest coefficient). Prolonged air leak was observed in 504 patients (9.9%). Three variables were found associated with prolonged air leak after logistic regression: male gender (P < .0001, score = 1), forced expiratory volume in 1 second less than 80% (P < .0001, score = 1), and body mass index less than 18.5 kg/m 2 (P < .0001, score = 2). The aggregate prolonged air leak risk score was calculated for each patient by summing the individual scores assigned to each variable (range, 0-4). Patients were then grouped into 4 classes with an incremental risk of prolonged air leak (P < .0001): class A (score 0 points, 1493 patients) 6.3% with prolonged air leak, class B (score 1 point, 2240 patients) 10% with prolonged air leak, class C (score 2 points, 1219 patients) 13% with prolonged air leak, and class D (score >2 points, 117 patients) 25% with prolonged air leak. An aggregate risk score was created to stratify the incidence of prolonged air leak after video-assisted thoracoscopic lobectomy. The score can be used for patient counseling and to identify those patients who can benefit from additional intraoperative preventative measures. Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Patient satisfaction with health-care professionals and structure is not affected by longer hospital stay and complications after lung resection: a case-matched analysis.

PubMed

Pompili, Cecilia; Tiberi, Michela; Salati, Michele; Refai, Majed; Xiumé, Francesco; Brunelli, Alessandro

2015-02-01

The objective of this investigation was to assess satisfaction with care of patients with long hospital stay (LHS) or complications after pulmonary resection in comparison with case-matched counterparts with a regular postoperative course. This is a prospective observational analysis on 171 consecutive patients submitted to pulmonary resections (78 wedges, 8 segmentectomies, 83 lobectomies, 3 pneumonectomies) for benign (35), primary (93) or secondary malignant (43) diseases. A hospital stay >7 days was defined as long (LHS). Major cardiopulmonary complications were defined according to the ESTS database. Patient satisfaction was assessed by the administration of the EORTC IN-PATSAT32 module at discharge. The questionnaire is a 32-item self-administered survey including different scales, reflecting the perceived level of satisfaction about the care provided by doctors, nurses and other personnel. To minimize selection bias, propensity score case-matching technique was applied to generate two sets of matched patients: patients with LHS with counterparts without it; patients with complications with counterparts without it. Median length of postoperative stay was 4 days (range 2-43). Forty-one patients (24%) had a hospital stay>7 days and 21 developed cardiopulmonary complications (12%). Propensity score yielded two well-matched groups of 41 patients with and without LHS. There were no significant differences in any patient satisfaction scale between the two groups. The comparison of the results of the patient satisfaction questionnaire between the two matched groups of 21 patients with and without complications did not show significant differences in any scale. Patients experiencing poor outcomes such as long hospital stay or complications have similar perception of quality of care compared with those with regular outcomes. Patient-reported outcome measures are becoming increasingly important in the evaluation of the quality of care and may complement more traditional objective indicators such as morbidity or length of stay. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Anæsthesia in Chest Surgery, with Special Reference to Controlled Respiration and Cyclopropane: (Section of Anæsthetics).

PubMed

Nosworthy, M D

1941-06-01

Problems in chest surgery: Cases with prolonged toxæmia or amyloid disease require an anæsthetic agent of low toxicity. When sputum or blood are present in the tracheobronchial tree the anæsthesia should abolish reflex distrubances and excessive sputum be removed by suction. The technique should permit the use of a high oxygen atmosphere; controlled respiration with cyclopropane or ether fulfil these requirements. Open pneumothorax is present when a wound of the chest wall allows air to pass in and out of the pleural cavity. The lung on the affected side collapses and the mediastinum moves over and partly compresses the other lung.The dangers of an open pneumothorax: (1) Paradoxical respiration-the lung on the affected side partially inflates on expiration and collapses on inspiration. Part of the air entering the good lung has been shuttled back from the lung on the affected side and is therefore vitiated. Full expansion of the sound lung is handicapped by the initial displacement of the mediastinum which increases on inspiration. The circulation becomes embarrassed.(2) Vicious circle coughing. During a paroxysm of coughing dyspnœa will occur. This accentuates paradoxical respiration and starts a vicious circle. Death from asphyxia may result.Special duties of the anæsthetist: (1) To carry out or supervise continuous circulatory resuscitation. During a thoracotomy a drip blood transfusion maintains normal blood-pressure and pulse-rate.(2) To maintain effcient respiration.Positive pressure anæsthesia: Risk of impacting secretions in smaller bronchi with subsequent atelectasis; eventual risk of CO(2) poisoning without premonitory signs.Controlled respiration: (1) How it is produced. (2) Its uses in chest surgery.Controlled respiration means that the anæsthetist, having abolished the active respiratory efforts of the patient, maintains an efficient tidal exchange by rhythmic squeezing of the breathing bag. This may be done mechanically by Crafoord's modification of Frenkner's spiropulsator or by hand.Active respiration will cease (i) if the patient's CO(2) is lowered sufficiently by hyperventilation, (ii) if the patient's respiratory centre is depressed sufficiently by sedative and anæsthetic drugs, and (iii) by a combination of (i) and (ii) of less degree.The author uses the second method, depressing the respiratory centre with omnoponscopolamine, pentothal sodium, and then cycloprȯpane. The CO(2) absorption method is essential for this technique, and this and controlled respiration should be mastered by the anæsthetist with a familiar agent and used at first only in uncomplicated cases.The significance of cardiac arrhythmias occuring with cyclopropane is discussed.The place of the other available anæsthetic agents is discussed particularly on the advisability of using local anæsthesia for the drainage of empyema or lung abscess.Pharyngeal airway or endotracheal tube? Anæsthesia may be maintained with a pharyngeal airway in many cases but intubation must be used when tracheobronchial suction may be necessary and when there may be difficulty in maintaining an unobstructed airway.A one-lung anæsthesia is ideal for pneumonectomy. This may be obtained by endotracheal anæsthesia after bronchial tamponage of the affected side (Crafoord, v. fig. 6b) or by an endobronchial intubation of the sound side (v. figs. 9b and 9c). Endobronchial placing of the breathing tube may be performed "blind". Before deciding on blind bronchial intubation, the anæsthetist must examine X-ray films for any abnormality deviating the trachea or bronchi. Though the right bronchus may be easily intubated blindly as a rule, there is the risk of occluding the orifice of the upper lobe bronchus (fig. 9d) when the patient will become cyanosed. If the tube bevel is facing its orifice the risk of occlusion will be decreased (fig. 9c).Greater accuracy in placing the tube can be effected by inserting it under direct vision. Instruments for performing this manœuvre are described.In lobectomy for bronchiectasis the anæsthetist must try to prevent the spread of infection to other parts. Ideally, the bronchus of the affected lobe should be plugged with ribbon gauze (Crafoord, v. fig. 6c) or a suction catheter with a baby balloon on it placed in the affected bronchus. In the presence of a large bronchopleural fistula controlled respiration cannot be established during operation. As the surgeon is rarely able to plug the fistula, if pneumonectomy is to be performed intubation for a one-lung anæsthesia is the best method. During other procedures it is essential to maintain quiet respiration.In war casualties it is almost always possible, with the technique described, to leave the lung on the affected side fully expanded and thus frequently to restore normal respiratory physiology. Co-operation between surgeon and anæsthetist is essential.

Anæsthesia in Chest Surgery, with Special Reference to Controlled Respiration and Cyclopropane

PubMed Central

Nosworthy, M. D.

1941-01-01

Problems in chest surgery: Cases with prolonged toxæmia or amyloid disease require an anæsthetic agent of low toxicity. When sputum or blood are present in the tracheobronchial tree the anæsthesia should abolish reflex distrubances and excessive sputum be removed by suction. The technique should permit the use of a high oxygen atmosphere; controlled respiration with cyclopropane or ether fulfil these requirements. Open pneumothorax is present when a wound of the chest wall allows air to pass in and out of the pleural cavity. The lung on the affected side collapses and the mediastinum moves over and partly compresses the other lung. The dangers of an open pneumothorax: (1) Paradoxical respiration—the lung on the affected side partially inflates on expiration and collapses on inspiration. Part of the air entering the good lung has been shuttled back from the lung on the affected side and is therefore vitiated. Full expansion of the sound lung is handicapped by the initial displacement of the mediastinum which increases on inspiration. The circulation becomes embarrassed. (2) Vicious circle coughing. During a paroxysm of coughing dyspnœa will occur. This accentuates paradoxical respiration and starts a vicious circle. Death from asphyxia may result. Special duties of the anæsthetist: (1) To carry out or supervise continuous circulatory resuscitation. During a thoracotomy a drip blood transfusion maintains normal blood-pressure and pulse-rate. (2) To maintain effcient respiration. Positive pressure anæsthesia: Risk of impacting secretions in smaller bronchi with subsequent atelectasis; eventual risk of CO2 poisoning without premonitory signs. Controlled respiration: (1) How it is produced. (2) Its uses in chest surgery. Controlled respiration means that the anæsthetist, having abolished the active respiratory efforts of the patient, maintains an efficient tidal exchange by rhythmic squeezing of the breathing bag. This may be done mechanically by Crafoord's modification of Frenkner's spiropulsator or by hand. Active respiration will cease (i) if the patient's CO2 is lowered sufficiently by hyperventilation, (ii) if the patient's respiratory centre is depressed sufficiently by sedative and anæsthetic drugs, and (iii) by a combination of (i) and (ii) of less degree. The author uses the second method, depressing the respiratory centre with omnoponscopolamine, pentothal sodium, and then cycloprȯpane. The CO2 absorption method is essential for this technique, and this and controlled respiration should be mastered by the anæsthetist with a familiar agent and used at first only in uncomplicated cases. The significance of cardiac arrhythmias occuring with cyclopropane is discussed. The place of the other available anæsthetic agents is discussed particularly on the advisability of using local anæsthesia for the drainage of empyema or lung abscess. Pharyngeal airway or endotracheal tube? Anæsthesia may be maintained with a pharyngeal airway in many cases but intubation must be used when tracheobronchial suction may be necessary and when there may be difficulty in maintaining an unobstructed airway. A one-lung anæsthesia is ideal for pneumonectomy. This may be obtained by endotracheal anæsthesia after bronchial tamponage of the affected side (Crafoord, v. fig. 6b) or by an endobronchial intubation of the sound side (v. figs. 9b and 9c). Endobronchial placing of the breathing tube may be performed “blind”. Before deciding on blind bronchial intubation, the anæsthetist must examine X-ray films for any abnormality deviating the trachea or bronchi. Though the right bronchus may be easily intubated blindly as a rule, there is the risk of occluding the orifice of the upper lobe bronchus (fig. 9d) when the patient will become cyanosed. If the tube bevel is facing its orifice the risk of occlusion will be decreased (fig. 9c). Greater accuracy in placing the tube can be effected by inserting it under direct vision. Instruments for performing this manœuvre are described. In lobectomy for bronchiectasis the anæsthetist must try to prevent the spread of infection to other parts. Ideally, the bronchus of the affected lobe should be plugged with ribbon gauze (Crafoord, v. fig. 6c) or a suction catheter with a baby balloon on it placed in the affected bronchus. In the presence of a large bronchopleural fistula controlled respiration cannot be established during operation. As the surgeon is rarely able to plug the fistula, if pneumonectomy is to be performed intubation for a one-lung anæsthesia is the best method. During other procedures it is essential to maintain quiet respiration. In war casualties it is almost always possible, with the technique described, to leave the lung on the affected side fully expanded and thus frequently to restore normal respiratory physiology. Co-operation between surgeon and anæsthetist is essential. PMID:19992357

Suction on chest drains following lung resection: evidence and practice are not aligned.

PubMed

Lang, Peter; Manickavasagar, Menaka; Burdett, Clare; Treasure, Tom; Fiorentino, Francesca

2016-02-01

A best evidence topic in Interactive CardioVascular and Thoracic Surgery (2006) looked at application of suction to chest drains following pulmonary lobectomy. After screening 391 papers, the authors analysed six studies (five randomized controlled trials [RCTs]) and found no evidence in favour of postoperative suction in terms of air leak duration, time to chest drain removal or length of stay. Indeed, suction was found to be detrimental in four studies. We sought to determine whether clinical practice is consistent with published evidence by surveying thoracic units nationally and performing a meta-analysis of current best evidence. We systematically searched MEDLINE, EMBASE and CENTRAL for RCTs, comparing outcomes with and without application of suction to chest drains after lung surgery. A meta-analysis was performed using RevMan(©) software. A questionnaire concerning chest drain management and suction use was emailed to a clinical representative in every thoracic unit. Eight RCTs, published 2001-13, with 31-500 participants, were suitable for meta-analysis. Suction prolonged length of stay (weighted mean difference [WMD] 1.74 days; 95% confidence interval [CI] 1.17-2.30), chest tube duration (WMD 1.77 days; 95% CI 1.47-2.07) and air leak duration (WMD 1.47 days; 95% CI 1.45-2.03). There was no difference in occurrence of prolonged air leak. Suction was associated with fewer instances of postoperative pneumothorax. Twenty-five of 39 thoracic units responded to the national survey. Suction is routinely used by all surgeons in 11 units, not by any surgeon in 5 and by some surgeons in 9. Of the 91 surgeons represented, 62 (68%) routinely used suction. Electronic drains are used in 15 units, 10 of which use them routinely. Application of suction to chest drains following non-pneumonectomy lung resection is common practice. Suction has an effect in hastening the removal of air and fluid in clinical experience but a policy of suction after lung resection has not been shown to offer improved clinical outcomes. Clinical practice is not aligned with Level 1a evidence. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Is uniportal thoracoscopic surgery a feasible approach for advanced stages of non-small cell lung cancer?

PubMed Central

Fieira, Eva; Delgado, Maria; Mendez, Lucía; Fernandez, Ricardo; de la Torre, Mercedes

2014-01-01

Objectives Conventional video-assisted thoracoscopic (VATS) lobectomy for advanced lung cancer is a feasible and safe surgery in experienced centers. The aim of this study is to assess the feasibility of uniportal VATS approach in the treatment of advanced non-small cell lung cancer (NSCLC) and compare the perioperative outcomes and survival with those in early-stage tumors operated through the uniportal approach. Methods From June 2010 to December 2012, we performed 163 uniportal VATS major pulmonary resections. Only NSCLC cases were included in this study (130 cases). Patients were divided into two groups: (A) early stage and (B) advanced cases (>5 cm, T3 or T4, or tumors requiring neoadjuvant treatment). A descriptive and retrospective study was performed, comparing perioperative outcomes and survival obtained in both groups. A survival analysis was performed with Kaplan-Meier curves and the log-rank test was used to compare survival between patients with early and advanced stages. Results A total of 130 cases were included in the study: 87 (A) vs. 43 (B) patients (conversion rate 1.1 vs. 6.5%, P=0.119). Mean global age was 64.9 years and 73.8% were men. The patient demographic data was similar in both groups. Upper lobectomies (A, 52 vs. B, 21 patients) and anatomic segmentectomies (A, 4 vs. B, 0) were more frequent in group A while pneumonectomy was more frequent in B (A, 1 vs. B, 6 patients). Surgical time was longer (144.9±41.3 vs. 183.2±48.9, P<0.001), and median number of lymph nodes (14 vs. 16, P=0.004) were statistically higher in advanced cases. Median number of nodal stations (5 vs. 5, P=0.165), days of chest tube (2 vs. 2, P=0.098), HOS (3 vs. 3, P=0.072), and rate of complications (17.2% vs. 14%, P=0.075) were similar in both groups. One patient died on the 58th postoperative day. The 30-month survival rate was 90% for the early stage group and 74% for advanced cases Conclusions Uniportal VATS lobectomy for advanced cases of NSCLC is a safe and reliable procedure that provides perioperative outcomes similar to those obtained in early stage tumours operated through this same technique. Further long term survival analyses are ongoing on a large number of patients. PMID:24976985

Intrapleural polymeric films containing cisplatin for malignant pleural mesothelioma in a rat tumour model: a preliminary study.

PubMed

Ampollini, Luca; Sonvico, Fabio; Barocelli, Elisabetta; Cavazzoni, Andrea; Bilancia, Rocco; Mucchino, Claudio; Cantoni, Anna Maria; Carbognani, Paolo

2010-03-01

This study aims to investigate the effect of intrapleural polymeric films containing cisplatin on the local recurrence of malignant pleural mesothelioma in a rat tumour model. An orthotopic rat recurrence model of malignant pleural mesothelioma was used. Five animals per group were evaluated. Polymeric films (4.5 cm diameter) for the local delivery of anticancer drug were constructed: hyaluronate, chitosan and the combined dual-layer polymers were loaded with cisplatin at a concentration of 100 mgm(-2). Animals without any adjuvant therapy were used as control. Mesothelioma cells were injected subpleurally in the anaesthetised rats. Six days later, a pleural tumour of 5.5mm was resected and a left pneumonectomy and pleural abrasion were performed. Thereafter, the cisplatin-loaded and unloaded films or cisplatin solution were intrapleurally applied, according to randomisation. After 6 days, animals were euthanised and organs harvested for morphological and histological evaluations. The primary endpoint was the volume of tumour recurrence. The secondary endpoints were treatment-related toxicity; cisplatin serum concentration evaluated at different time points; and cisplatin concentration in the pleura measured at autopsy. Analysis of variance (ANOVA) was used for statistical analysis. Bonferroni correction was applied for comparison between all groups. Tumour volume was significantly reduced in the hyaluronate cisplatin and hyaluronate-chitosan cisplatin groups in comparison to control groups (p=0.001 and p<0.0001, respectively). Animals treated with hyaluronate-chitosan cisplatin had a tumour recurrence significantly lesser than animals treated with cisplatin solution (p=0.003) and hyaluronate cisplatin (p=0.032). No toxicity related to the different treatments was observed. On postoperative days 1 and 2, cisplatin was detected in the serum at a concentration six- and sevenfold significantly higher in the hyaluronate cisplatin and hyaluronate-chitosan cisplatin groups, in comparison to cisplatin solution, and was maintained over time. Cisplatin levels in the pleura were higher in the hyaluronate-chitosan cisplatin group than in all others. Hyaluronate-chitosan cisplatin was significantly effective in reducing tumour recurrence compared with cisplatin solution. Hyaluronate and hyaluronate-chitosan loaded with cisplatin assured significantly higher and more prolonged plasmatic drug concentrations than cisplatin solution without increasing toxicity. Copyright (c) 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

[Open window thoracostomy and muscle flap transposition for thoracic empyema].

PubMed

Nakajima, Y

2010-07-01

Open window thoracostomy for thoracic empyema: Open window thoracostomy is a simple, certain and final drainage procedure for thoracic empyema. It is most useful to drain purulent effusion from empyema space, especially for cases with broncho-pleural fistulas, and to clean up purulent necrotic debris on surface of empyema sac. For changing of packing gauzes in empyema space through a window once or twice every day after this procedure, thoracostomy will have to be made on the suitable position to empyema space. Usually skin incision will be layed along the costal bone just at the most expanded position of empyema. Following muscle splitting to thoracic wall, a costal bone just under the incision will be removed as 8-10 cm as long, and opened the empyema space through a costal bed. After the extension of empyema space will be preliminarily examined through a primary window by a finger or a long forceps, it will be decided costal bones must be removed how many (usually 2 or 3 totally) and how long (6-8 cm) to make a window up to 5 cm in diameter. Thickened empyema wall will be cut out just according to a window size, and finally skin edge and empyema wall will be sutured roughly along circular edge. Muscle flap transposition for empyema space: Pediclued muscle flap transposition is one of space-reducing operations for (chronic) empyema Usually this will be co-performed with other several procedures as curettages on empyema surface, closure of bronchopleural fistula and thoracoplasty. This is radically curable for primarily non fistulous empyema or secondarily empyema after open window thoracostomy done for fistula. Furthermore this is less invasive than other radical operations as like pleuro-pneumonectomy, decortication or air-plombage for empyema. There are 2 important points to do this technique. One is a volume of muscle flap and another is good blood flow in flap. The former suitable muscle volume is need to impact empyema space or to close fistula, and the latter over-elongation and bending of pedicles should be avoided. Actually, after removing several costal bones on the empyema space, empyema wall will be incised for about 2/3 of total empyema length along costal beds. Then muscle flap will be introduced into cleaned up space and sutured on empyema surface at several points. It is better to lay small vacuum drain tubes along flap within empyema space.

Fatal pneumonitis associated with intensity-modulated radiation therapy for mesothelioma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Allen, Aaron M.; Czerminska, Maria; Jaenne, Pasi A.

2006-07-01

Purpose: To describe the initial experience at Dana-Farber Cancer Institute/Brigham and Women's Hospital with intensity-modulated radiation therapy (IMRT) as adjuvant therapy after extrapleural pneumonectomy (EPP) and adjuvant chemotherapy. Methods and Materials: The medical records of patients treated with IMRT after EPP and adjuvant chemotherapy were retrospectively reviewed. IMRT was given to a dose of 54 Gy to the clinical target volume in 1.8 Gy daily fractions. Treatment was delivered with a dynamic multileaf collimator using a sliding window technique. Eleven of 13 patients received heated intraoperative cisplatin chemotherapy (225 mg/m{sup 2}). Two patients received neoadjuvant intravenous cisplatin/pemetrexed, and 10 patientsmore » received adjuvant cisplatin/pemetrexed chemotherapy after EPP but before radiation therapy. All patients received at least 2 cycles of intravenous chemotherapy. The contralateral lung was limited to a V20 (volume of lung receiving 20 Gy or more) of 20% and a mean lung dose (MLD) of 15 Gy. All patients underwent fluorodeoxyglucose positron emission tomography (FDG-PET) for staging, and any FDG-avid areas in the hemithorax were given a simultaneous boost of radiotherapy to 60 Gy. Statistical comparisons were done using two-sided t test. Results: Thirteen patients were treated with IMRT from December 2004 to September 2005. Six patients developed fatal pneumonitis after treatment. The median time from completion of IMRT to the onset of radiation pneumonitis was 30 days (range 5-57 days). Thirty percent of patients (4 of 13) developed acute Grade 3 nausea and vomiting. One patient developed acute Grade 3 thrombocytopenia. The median V20, MLD, and V5 (volume of lung receiving 5 Gy or more) for the patients who developed pneumonitis was 17.6% (range, 15.3-22.3%), 15.2 Gy (range, 13.3-17 Gy), and 98.6% (range, 81-100%), respectively, as compared with 10.9% (range, 5.5-24.7%) (p = 0.08), 12.9 Gy (range, 8.7-16.9 Gy) (p = 0.07), and 90% (range, 66-98.3%) (p = 0.20), respectively, for the patients who did not develop pneumonitis. Conclusions: Intensity-modulated RT treatment for mesothelioma after EPP and adjuvant chemotherapy resulted in a high rate of fatal pneumonitis when standard dose parameters were used. We therefore recommend caution in the utilization of this technique. Our data suggest that with IMRT, metrics such as V5 and MLD should be considered in addition to V20 to determine tolerance levels in future patients.« less

[Video-assisted thoracoscopic anatomic lung resection: experience of 246 operations].

PubMed

Pishchik, V G; Zinchenko, E I; Obornev, A D; Kovalenko, A I

2016-01-01

To present one of the largest materials of video-assisted thoracoscopic (VATS) anatomic lung resections in Russia. It is a retrospective analysis of treatment of 246 patients who underwent VATS anatomic lung resection for the period from 2010 to 2014 at the Center for Thoracic Surgery of St. Petersburg Clinical Hospital №122. One surgical team has operated 125 men and 121 women aged from 20 to 85 years (58.8±13.4 years). There were 216 (87.8%) lobectomies, 4 (1.6%) bilobectomies, 9 (3.7%) pneumonectomies, 10 (4.1%) segmentectomies and 7 (2.8%) trisegmentectomies. Upper right-side lobectomy was the most frequent in this group (87 (40.3%)). Most of operations was performed via 2 approaches (119 patients). Average length of the longest incision was 4.3±0.93 cm (range 2-6 cm). All patients were examined according to a single plan. FEV1 less than 70% was observed in 26% of patients; comorbidity index was 5 scores or more in 24% of cases; 23.2% of patients were older than 70 years. Non-small cell lung cancer (NSCLC) was diagnosed in 168 patients (68.3%), pulmonary tuberculosis - in 27 (11%), chronic suppurative lung disease - in 27 (11%) cases. Furthermore there were 9 cases of pulmonary metastases, 11 cases of carcinoid, 1 - MALT-lymphoma, 1 - leiomyoma, 2 - small cell lung cancer, as well as one case of IgG-associated pseudotumor. Among 168 cases of NSCLC operations were performed in 87 (51.8%) cases for cancer stage I, in 46 (27.3%) patients for stage II, in 27 patients for stage III (including 16 cases of stage IIIA and 11 cases of stage IIIB). 8 patients (4.7%) with lung cancer stage IV have been operated in radical surgery for solitary metastasis. Mean duration of surgery was 202.1±58.2 minutes (range 100-380). On the average 12.8±5.6 (range 9-32) mediastinal lymph nodes were excised during lymph node dissection in cancer patients. Mean number of nodes groups was 4.1±1.1. In 11 (4.5%) patients conversion to open surgery was made due to intraoperative bleeding (3 cases) and technical difficulties (8 cases). Mean duration of postoperative pleural drainage and hospital-stay were 5.1±4.3 (median - 3 days) and 7.9±4.7 days (median - 6 days) respectively. Complications which were not associated with perioperative deaths were observed in 66 patients (26.8%). Prolonged air vent was the most common complication. VATS anatomical lung resections are safe and effective in most of pulmonary surgical diseases. Such interventions may be recommended for wider introduction at the Thoracic Departments of Russia because of small number of complications and rapid rehabilitation. Bleeding or its risk associated with fibrotic changes in pulmonary root are the most frequent causes of conversion to open access.

[When Should We Perform Surgery for N2 Lung Cancer?;Induction Chemoradiotherapy or Surgery for Local Recurrence or Residual Tumor after Definitive Chemoradiotherapy].

PubMed

Ito, Hiroyuki; Nakayama, Haruhiko

2018-04-01

Standard treatment for locally advanced clinical N2 lung cancer is definitive chemoradiotherapy, and induction chemoradiotherapy(IND-CRT) followed by surgery is an option. Most of them recurs remotely within a few years after initial therapy. Patients who received salvage surgery(SAL) after definitive chemoradiotherapy had no remote relapse for some period after definitive chemoradiotherapy, thus the outcome of SAL may be better than those of IND-CRT, but the operative risks of both procedures seem to be high. To compare the prognosis and risk of SAL and IND-CRT. From January 2001 through December 2015, 39 patients with clinical N2 primary lung cancer underwent surgery after chemoradiotherapy. Twenty-six patients received IND-CRT, and 13 underwent SAL. Perioperative factors, overall survival rates at 5 years, lung-cancer-specific mortality, relapse-free survival rates, and the rates of perioperative complications were compared between the groups. The median follow up period was 41.0 months(5~120 months). Twelve patients were women, and 27 were men. The average age was 60.2 years. The patients comprised 1.7% of the 2,330 anatomical resections performed during the same period. The radiation dose was 46.4 Gy who received IND-CRT and 61.4 Gy in those who received SAL(p<0.001). In patients who received IND-CRT, median period from the end of the initial treatment to surgery was 1.2 months in IND-CRT and 17.2 months in SAL. Lobectomy was performed in 37 patients, pneumonectomy in 2 patients. In patients who received IND-CRT, an average operation time was 236 minutes, mean bleeding volume was 135 g. In patients who underwent SAL, they were 236 minutes and 188 g(p=0.998, p=0.365). There was no perioperative and in-hospital death in either group. Postoperative complications developed in 5 of INDCRT(19.2%)and 3 in SAL(23.1%). The 5-year overall survival rate of all cases was 60.4%(IND-CRT 53.9, SAL 81.8%;p=0.737). The lung cancer-specific survival rate at 5 years was 60.4% overall, 57.5% in IND-CRT, and 90.0% in SAL(p=0.176). The 5-year relapse-free survival rate was 52.7% overall, 37.6% in IND-CRT, 57.7% in SAL(p=0.175). Although the differences were not statistically significant, SAL tended to have better outcomes. SAL did not differ significantly from IND-CRT with respect to postoperative complications or surgical invasiveness in patients with clinical N2 lung cancer and had good outcomes. SAL and IND-CRT seem to be a sufficiently meaningful treatment but should be performed by surgeons with sufficient knowledge and experience.

Erector spinae plane (ESP) block in the management of post thoracotomy pain syndrome: A case series.

PubMed

Forero, Mauricio; Rajarathinam, Manikandan; Adhikary, Sanjib; Chin, Ki Jinn

2017-10-01

Post thoracotomy pain syndrome (PTPS) remains a common complication of thoracic surgery with significant impact on patients' quality of life. Management usually involves a multidisciplinary approach that includes oral and topical analgesics, performing appropriate interventional techniques, and coordinating additional care such as physiotherapy, psychotherapy and rehabilitation. A variety of interventional procedures have been described to treat PTPS that is inadequately managed with systemic or topical analgesics. Most of these procedures are technically complex and are associated with risks and complications due to the proximity of the targets to neuraxial structures and pleura. The ultrasound-guided erector spinae plane (ESP) block is a novel technique for thoracic analgesia that promises to be a relatively simple and safe alternative to more complex and invasive techniques of neural blockade. We have explored the application of the ESP block in the management of PTPS and report our preliminary experience to illustrate its therapeutic potential. The ESP block was performed in a pain clinic setting in a cohort of 7 patients with PTPS following thoracic surgery with lobectomy or pneumonectomy for lung cancer. The blocks were performed with ultrasound guidance by injecting 20-30mL of ropivacaine, with or without steroid, into a fascial plane between the deep surface of erector spinae muscle and the transverse processes of the thoracic vertebrae. This paraspinal tissue plane is distant from the pleura and the neuraxis, thus minimizing the risk of complications associated with injury to these structures. The patients were followed up by telephone one week after each block and reviewed in the clinic 4-6 weeks later to evaluate the analgesic response as well as the need for further injections and modification to the overall analgesic plan. All the patients had excellent immediate pain relief following each ESP block, and 4 out of the 7 patients experienced prolonged analgesic benefit lasting 2 weeks or more. The ESP blocks were combined with optimization of multimodal analgesia, resulting in significant improvement in the pain experience in all patients. No complications related to the blocks were seen. The results observed in this case series indicate that the ESP block may be a valuable therapeutic option in the management of PTPS. Its immediate analgesic efficacy provides patients with temporary symptomatic relief while other aspects of chronic pain management are optimized, and it may also often confer prolonged analgesia. The relative simplicity and safety of the ESP block offer advantages over other interventional procedures for thoracic pain; there are few contraindications, the risk of serious complications (apart from local anesthetic systemic toxicity) is minimal, and it can be performed in an outpatient clinic setting. This, combined with the immediate and profound analgesia that follows the block, makes it an attractive option in the management of intractable chronic thoracic pain. The ESP block may also be applied to management of acute pain management following thoracotomy or thoracic trauma (e.g. rib fractures), with similar analgesic benefits expected. Further studies to validate our observations are warranted. Copyright © 2017 Scandinavian Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

Micro-imaging of the Mouse Lung via MRI

NASA Astrophysics Data System (ADS)

Wang, Wei

Quantitative measurement of lung microstructure is of great significance in assessment of pulmonary disease, particularly in the earliest stages. Conventional stereological assessment of ex-vivo fixed tissue specimens under the microscope has a long and successful tradition and is regarded as a gold standard, but the invasive nature limits its applications and the practicality of use in longitudinal studies. The technique for diffusion MRI-based 3He lung morphometry was previously developed and validated for human lungs, and was recently extended to ex-vivo mouse lungs. The technique yields accurate, quantitative information about the microstructure and geometry of acinar airways. In this dissertation, the 3He lung morphometry technique is for the first time successfully implemented for in-vivo studies of mice. It can generate spatially-resolved maps of parameters that reveal the microstructure of mouse lung. Results in healthy mice indicate excellent agreement between in-vivo morphometry via 3He MRI and microscopic morphometry after sacrifice. The implementation and validation of 3He morphometry in healthy mice open up new avenues for application of the technique as a precise, noninvasive, in-vivo biomarker of changes in lung microstructure, within various mouse models of lung disease. We have applied 3He morphometry to the Sendai mouse model of lung disease. Specifically, the Sendai-virus model of chronic obstructive lung disease has demonstrated an innate immune response in mouse airways that exhibits similarities to the chronic airway inflammation in human COPD and asthma, but the effect on distal lung parenchyma had not been investigated. We imaged the time course and regional distribution of mouse lung microstructural changes in vivo after Sendai virus (SeV) infection with 1H and 3He diffusion MRI. 1H MR images detected the SeV-induced pulmonary inflammation in vivo and 3He lung morphometry showed modest increase in alveolar duct radius distal to airway inflammation, particularly in the lung periphery, indicating airspace enlargement after virus infection. Another important application of the imaging technique is the study of lung regeneration in a pneumonectomy (PNX) model. Partial resection of the lung by unilateral PNX is a robust model of compensatory lung growth. It is typically studied by postmortem morphometry in which longitudinal assessment in the same animal cannot be achieved. Here we successfully assess the microstructural changes and quantify the compensatory lung growth in vivo in the PNX mouse model via 1H and hyperpolarized 3He diffusion MRI. Our results show complete restoration in lung volume and total alveolar number with enlargement of alveolar size, which is consistent with prior histological studies conducted in different animals at various time points. This dissertation demonstrates that 3He lung morphometry has good sensitivity in quantifying small microstructural changes in the mouse lung and can be applied to a variety of mouse pulmonary models. Particularly, it has great potential to become a valuable tool in understanding the time course and the mechanism of lung growth in individual animals and may provide insight into post-natal lung growth and lung regeneration.

[A Germany-wide survey on anaesthesia in thoracic surgery].

PubMed

Defosse, J; Schieren, M; Böhmer, A; von Dossow, V; Loop, T; Wappler, F; Gerbershagen, M U

2016-06-01

This study's objective was to evaluate current thoracic anaesthesia practice in Germany and to quantify potential differences depending on the hospital's level of care. A four-part online survey containing 28 questions was mailed to all anaesthesiology department chairs (n = 777) registered with the German Society of Anaesthesiology and Intensive Care Medicine. The general response rate was 31.5 % (n = 245). High monthly volumes (>50 operations/month) of intrathoracic procedures, performed by specialized thoracic surgeons are mostly limited to hospitals of maximum care, university hospitals, and specialized thoracic clinics. In hospitals with a lower level of care, intrathoracic operations occur less frequently (1-5/month) and are commonly performed by general (69.3 %) rather than thoracic surgeons (15.4 %). Video-assisted thoracic surgeries are the most invasive intrathoracic procedures for most hospitals with a low level of care (61.5 %). Extended resections and pneumonectomies occur mainly in hospitals of maximum care and university hospitals. Thoracic anaesthesia is primarily performed by consultants or senior physicians (59.9 %). The double lumen tube (91.4 %) is the preferred method to enable one-lung ventilation (bronchial blockers: 2.7 %; missing answer: 5.9 %). A bronchoscopic confirmation of the correct placement of a double lumen tube is considered mandatory by 87.7 % of the respondents. Bronchial blockers are available in 64.7 % of all thoracic anaesthesia departments. While CPAP-valves for the deflated lung are commonly used (74.9 %), jet-ventilators are rarely accessible, especially in hospitals with a lower level of care (15.4 %). Although general algorithms for a difficult airway are widely available (87.7 %), specific recommendations for a difficult airway in thoracic anaesthesia are uncommon (4.8 %). Laryngeal mask airways (90.9 %) and videolaryngoscopy (88.8 %) are the primary adjuncts in store for a difficult airway. While hospitals with a lower level of care admitted patients routinely (92.3 %) to an intensive care unit after thoracic surgery, larger clinics used the postanaesthesia recovery room (12.5 %) and intermediate care units (14.6 %) more frequently for further surveillance. Thoracic epidural catheters (85.6 %) are predominantly chosen for peri- and postoperative analgesia, in contrast to paravertebral blockade (single shot: 8.6 %; catheter: 8.0 %) (multiple answers possible). Ultrasound is generally accessible (84.5 %) and mostly employed for the placement of central venous (81.3 %) and arterial (43.9 %) lines as well as a diagnostic tool for pulmonary pathology (62.0 %). The study reveals considerable differences in the anaesthetic practice in thoracic surgery. These focus mostly on the postoperative surveillance, the availability of bronchial blockers, and the use of regional anaesthetic techniques. Furthermore, it is evident that specific algorithms are needed for the difficult airway in thoracic anaesthesia. A recommendation for the high-tech work environment of thoracic anaesthesia could enhance the structural quality and optimize patient outcomes. Independent of a hospital's level of care, uniform requirements could help establish national quality standards in thoracic anaesthesia.

[Expression of high mobility group box-1 in the lung tissue and serum of patients with pulmonary tuberculosis].

PubMed

Yang, Xiao-min; Yang, Hua

2013-07-01

To explore the expression of high mobility group box-1 (HMGB1) in the lung tissue and serum of patients with pulmonary tuberculosis and to explore its relationship with tumor necrosis factor (TNF)-α and interleukin(IL)-1β. Sixty samples of lung tissues were obtained from patients with pulmonary tuberculosis who had underwent pneumonectomy in Department of Chest Surgery, First Affiliated Hospital of Zunyi Medical College from June 2010 to December 2011. At the same period, 40 normal lung samples were also obtained from patients with pulmonary contusion and lung cancer by surgical resections as the control group. The mRNA expressions of HMGB1 was detected by reverse transcription-polymerase chain reaction (RT-PCR), and the protein level of HMGB1 was measured by immunohistochemical staining of tissue microarrays in lung tissue. Blood samples were taken from 89 patients with active pulmonary tuberculosis (pulmonary tuberculosis group), including hematogenous disseminated pulmonary tuberculosis (type II) in 35 cases and secondary pulmonary tuberculosis (type III) in 54 cases, and 50 healthy volunteers (control group). Furthermore, the 54 patients with secondary pulmonary tuberculosis were divided into different subgroups according to cavity formation and the lung fields involved: patients without lung cavity (35 cases) vs those with lung cavity (19 cases), patients with involvement of <2 lung fields (31 cases) vs ≥ 2 lung fields (23 cases). Serum concentration of HMGB1, TNF-α and IL-1β were detected by ELISA. Two sample t-test was used to compare date among groups, liner correlation analysis was established for correlation analysis. The average optical density of HMGB1 in pulmonary tuberculosis (69 ± 29) was significantly higher than that in normal lung tissue (22 ± 12) (t = 2.389, P < 0.05). The mRNA relative transcript levels of HMGB1 in pulmonary tuberculosis (786 ± 86) was significantly higher than that in normal lung tissue (202 ± 60) (t = 3.872, P < 0.01). The serum concentration of HMGB1, TNF-α and IL-1β in the pulmonary tuberculosis group were (5.0 ± 3.2) µg/L, (118 ± 77) ng/L and (33 ± 20) ng/L, respectively, which were significantly higher than those in the control group [(1.7 ± 1.0) µg/L, (40 ± 11) ng/L and (18 ± 12) ng/L, respectively], the respective t values being -0.928, 4.268 and 11.064, all P < 0.01. In the subgroup of patients with hematogenous disseminated pulmonary tuberculosis, the serum concentration of HMGB1 and TNF-α[ (6.4 ± 3.3) µg/L, (147 ± 89) ng/L] were significantly higher than those in patients with secondary pulmonary tuberculosis [(4.1 ± 2.7) µg/L, (85 ± 37) ng/L] (t = 3.643 and t = 3.111, both P < 0.01). HMGB1 were correlated positively with TNF-α and IL-1β (r = 0.722 and r = 0.620, P < 0.01, respectively, n = 89) in the pulmonary tuberculosis group. Overexpression of HMGB1 in the lung tissue and serum of patients with pulmonary tuberculosis may play an important role in the inflammatory response of pulmonary tuberculosis. The measurement of serum HMGB1 is useful to evaluate the severity of disease.

The clinical presentations of pulmonary aspergillosis in children with cystic fibrosis - preliminary report.

PubMed

Walicka-Serzysko, Katarzyna; Sands, Dorota

2015-01-01

Pulmonary aspergillosis is a very serious complication in cystic fibrosis (CF) patients due to the great variety of its clinical presentations and the fact that it worsens the prognosis. We can distinguish the following: Aspergillus colonization (AC), Aspergillus infection (AI) and allergic bronchopulmonary aspergillosis (ABPA). Aspergillus colonization (AC) is defined as isolation of Aspergillus spp. from 50% ormore sputum samples over six months to one year without observing deterioration in lung function and an increase in such respiratory symptoms as cough. Aspergillus infection (AI) is diagnosed in subjects with Aspergillus colonization and a decline in lung function, respiratory exacerbation with and without cough or with an incomplete response to a 2-4 week course of appropriate broad-spectrum antibiotics. Aspergillus can also cause allergic bronchopulmonary aspergillosis (ABPA). The classic diagnostic criteria of allergic bronchopulmonary aspergillosis in cystic fibrosis have been established during the Cystic Fibrosis Foundation Conference in 2001. To establish the prevalence of pulmonary aspergillosis in children with cystic fibrosis under the care of our centre and to investigate the potential predisposing factors to Aspergillus infection (AI) and allergic bronchopulmonary aspergillosis (ABPA). An analysis was conducted of the medical documentation of 374 children aged 0-18 years monitored regularly in the Cystic Fibrosis Centre of the Institute of Mother and Child in Warsaw from 01.01.2010 to 31.08.2014. We selected 13 patients who presented an evidently worsening clinical status and course of the bronchopulmonary disease (decline in lung function parameters, respiratory exacerbations with increased cough, new or recent abnormalities in chest imaging) despite standard treatment with a high calorie diet, supplementation of pancreatic enzymes and vitamins, dornase alpha, inhaled and/or oral antibiotics, inhaled or oral corticosteroids, bronchodilators, physiotherapy. In this group of 13 CF children Aspergillus fumigatus was isolated from sputum. They represented 3.5% of the patients treated in our centre. Pulmonary aspergillosis was analyzed in relation to the age, sex, genotype, exocrine pancreatic insufficiency, body mass index, pulmonary function, microbiological examination of sputum, pulmonary complications and therapies. The mean age was 10.7 years (range 4.5-16.3). Only one child was under the age of six years. Patients were divided into 3 groups: patients with Aspergillus infection (AI), patients with allergic bronchopulmonary aspergillosis (ABPA), and a patient with Aspergillus infection and bronchopulmonary aspergillosis. Aspergillus infection (AI) was diagnosed in 9 cases (2.4%) and allergic bronchopulmonary aspergillosis (ABPA) in 3 (0.8%). One patient was treated with corticosteroids, because of allergic bronchopulmonary aspergillosis (ABPA) and after 8 months he developed Aspergillus infection (AI).n Most of the children were homo- or heterozygous for mutation F508del. Pancreatic insufficiency was recognized in all the children with ABPA, most of those with AI (8/9) and in one boy with ABPA and AI. Most of the patients had chronic respiratory colonization of Staphylococcus aureus and Pseudomonas aeruginosa. Children with AI were older (mean age:12.4), had a worse nutritional status (three of them had aBMI 3rd percentile), poorer lung function (five had severe lung disease *FEV1 40%*, complications occurred in one of the underlying diseases *haemoptysis, CFRD - Cystic Fibrosis Related Diabetes*, two of them had vascuport inserted due to the need for frequent intravenous antibiotic therapy. All the patients received inhaled antibiotics. A long-term oral azithromycin regime was applied in all the children with allergic bronchopulmonary aspergillosis, in most of those with Aspergillus infection *6,9* and in one boy with ABPA and AI. In three patients diagnosed with Aspergillus infection, antifungal treatment did not give any clinical or radiological improvement. They underwent surgical resection in the Department of Thoracic Surgery in Rabka (Poland). One patient had pneumonectomy and two underwent lobectomies. One boy had lung transplantation in Rigshospitalet in Copenhagen nine months after being diagnosed with Aspergillus infection. Since pulmonary aspergillosis is a very serious complication in CF children, it seems reasonable to include screening for early detection of Aspergillus colonization in the annual assessment of CF patients who are over 6 years old. Due to the small sample size and retrospective design of our analysis, the identification of risk factors of pulmonary aspergillosis in CF children require further prospective studies. .