Evaluation of lung cancer metastases to the spine.

Most metastatic spinal lesions (70%) are found at the thoracic level, 20% in the lumbar region, and 10% in the cervical region. A variety of benign and malignant tumours may arise in the lung, but the vast majority is bronchogenic carcinomas (90 to 95%). The aim of this study was to evaluate the lung cancer metastases to the vertebral column in terms of type, localisation and metastasis pattern. Between the years 1995 and 2003, 168 lung cancer patients with metastatic spinal tumour who had received radiotherapy and chemotherapy were retrospectively evaluated. The total number of vertebrae in which metastases were detected was 328. The most common site for metastasis was the thoracic spine. In 49 (29%) patients, there was only one vertebral involvement. Additional extravertebral bony metastases were present in 37 (22%) patients; the femur (20 patients) was the most common site. Only 25 of 168 patients were operated due to spinal cord compression leading to neurological deficit. The rest of the patients were treated by appropriate chemotherapy and radiotherapy protocols. The mean survival after diagnosis of vertebral metastasis was 7.1 months. Squamous cell carcinoma and adenocarcinoma are the lung cancers that mostly metastasise to vertebrae. Most of the metastases involve multiple spinal levels. After the diagnosis of vertebral metastasis, the mean survival is seven months. Pain relief and maintaining quality of life must be balanced with the patient's life expectancy, comorbidities and immunological, nutritional and functional status in treatment decision.

Preoperative multiple-injection thoracic paravertebral blocks reduce postoperative pain and analgesic requirements after video-assisted thoracic surgery.

OBJECTIVE: The hypothesis was tested that preoperative multiple-injection thoracic paravertebral blocks reduce opioid requirements and promote early ambulation after video-assisted thoracic surgery procedures. DESIGN: Prospective, randomized, controlled, blinded study. SETTING: Single-university hospital. PARTICIPANTS: Fifty consenting patients undergoing video-assisted thoracic surgery. INTERVENTIONS: Patients were randomly assigned to receive preoperative multiple-injection thoracic paravertebral blocks (PVB group, n = 25) or preoperative multiple subcutaneous saline injections at the same site as in the PVB group (control group, n = 25). MEASUREMENTS AND MAIN RESULTS: Intraoperative fentanyl consumption was lower in the PVB group (p < 0.01). The time to first analgesic requirement was longer, and pain score at this time was lower in the PVB group (p < 0.05 and p < 0.01, respectively). Postoperative pain scores both at rest and coughing were lower during the first 4 hours in the PVB group than those in the control group (p < 0.01 for 0 hours and p < 0.05 for 1, 2, and 4 hours). Cumulative morphine consumption was significantly less in the PVB group at all time points (p < 0.05 for 12 hours and p < 0.01 for all other time points), but there were no significant differences in sedation scores between the 2 groups. There were no complications because of the blocks. Patient satisfaction with the analgesia was significantly greater (p < 0.05), and first mobilization and hospital discharge were quicker (p < 0.01 and p < 0.05, respectively) in the PVB group. CONCLUSION: Perioperative multiple-injection thoracic paravertebral blocks with bupivacaine containing epinephrine provided effective pain relief and a significant reduction in opioid requirements. This approach may also contribute to earlier postoperative ambulation after video-assisted thoracic surgery.

Invasive pulmonary aspergillosis: role of early diagnosis and surgical treatment in patients with acute leukemia.

BACKGROUND: Aspergillus is a ubiquitous soil-dwelling fungus known to cause significant pulmonary infection in immunocompromised patients. The incidence of aspergillosis has increased during the past two decades and is a frequently lethal complication of acute leukemia patients that occurs following both chemotherapy and bone marrow transplantation. The diagnosis of invasive pulmonary aspergillosis (IPA) according to the criteria that are established by European Organization for the Research and Treatment of Cancer and Mycoses Study Group raise difficulties in severely ill patients. Despite established improvements in field of diagnosis (galactomannan antigen, quantitative PCR, real-time PCR for Aspergillus spp., and findings of computed tomography) and treatment with new antifungals, it is still a major problem in patients with acute leukemia. However, prompt and effective treatment of IPA is crucial because most patients will need subsequent chemotherapy for underlying hematologic disease as soon as possible. CASE PRESENTATION: We report a 33-year-old male patient with acute promyelocytic leukemia diagnosed in 1993 that developed invasive pulmonary aspergillosis due to A. flavus at relapse in 2003. The patient was successfully treated with liposomal amphotericin B and underwent surgical pulmonary resection. The operative course was uneventful. CONCLUSION: This report emphasizes the clinical picture, applicability of recent advances in diagnostic and therapeutic approaches for IPA. For early identification of a patient infected with IPA, a high index of suspicion and careful clinical and radiological examinations with serial screening for galactomannan should be established. If aspergillosis is suspected, anti-aspergillosis drug should be administered immediately, and if a unique pulmonary lesion remains, surgical resection should be considered to prevent reactivation during consecutive chemotherapy courses and to improve the outcome.

Comparison of lumbar epidural tramadol and lumbar epidural morphine for pain relief after thoracotomy: a repeated-dose study.

OBJECTIVE: The purpose of this study was to compare lumbar epidural morphine and lumbar epidural tramadol with respect to onset and duration of analgesia, analgesic efficacy, and drug-related side effects after muscle-sparing thoracotomy. DESIGN: Prospective, randomized, double-blind, clinical study. SETTING: Single university hospital. PARTICIPANTS: Forty patients who underwent elective muscle-sparing thoracotomy. INTERVENTIONS: Before anesthesia induction, an epidural catheter was placed in the L2-3 or L3-4 interspace using the loss-of-resistance technique. On arrival at the intensive care unit, patients were randomized to receive doses of either 100 mg of tramadol (group T) or 4 mg of morphine (group M) via the lumbar epidural catheter. Each dose was diluted in 10 mL of normal saline. On awakening from anesthesia, if the patient's pain score on a 0- to 100-mm visual analog scale was above 40 mm, the initial epidural drug dose was administered. The initial injection in each case was taken as time 0. Subsequent pain scores above 40 mm were considered indications for epidural dosing; each patient was allowed 2 doses in the first 12 hours postoperatively and 2 more in the second 12 hours. MEASUREMENTS AND MAIN RESULTS: The groups' analgesia onset times were similar, but duration of analgesia was significantly shorter in group T than in group M (p < 0.01). There were no differences between the groups with respect to pain scores at rest or during coughing at any of the time points investigated. Sedation scores were lower in group T than in group M at 1, 2, 3, 4, and 8 hours (p value range, 0.0001-0.05). Compared with group T, group M showed significantly greater drops in arterial oxygen tension from baseline at 3, 4, 8, and 12 hours (p value range, 0.0001-0.05). The group means for arterial carbon dioxide tension and respiratory rate were similar at all time points investigated. CONCLUSION: The study revealed that the quality of analgesia achieved with repeated doses of lumbar epidural tramadol after muscle-sparing thoracotomy is comparable to that achieved with repeated doses of lumbar epidural morphine. Compared with morphine, lumbar epidural tramadol results in less sedation and a less-pronounced decrease in oxygenation.

Bronchopulmonary sequestration: radiologic findings.

Bronchopulmonary sequestration (BPS) is a nonfunctioning bronchopulmonary tissue that is separate from the tracheobronchial tree and receives arterial blood from the systemic circulation. BPS has a wide spectrum of imaging findings. Surgery is generally indicated for the treatment of BPS. It is important to demonstrate the arterial supply and venous drainage of the sequestered segment preoperatively. Today, with the help of noninvasive imaging techniques such as computed tomography (CT) and magnetic resonance imaging (MRI), preoperative diagnosis of BPS can be made easily, so, invasive techniques such as angiography are not required frequently. In this report, radiological findings of BPS were retrospectively reviewed.

Surgical approach in T4N0M0 (vertebral involvement) lung cancer.

Approximately 5% of the cancers involve the chest wall and spine by direct extension and remain localized at the time of diagnosis. T4 lesions invading the vertebra are considered inoperable. We reviewed a new evolution in the surgical treatment of lung cancer involving the vertebra (T4N0M0) and report preliminary results of our approach. Four patients with T4N0M0 (vertebral involvement) lung cancer underwent en bloc surgical resection of tumor between 1998 and 2002. Posterior stabilization, hemilaminectomy, and osteotomy of the involved vertebral bodies below the corresponding pedicle were performed in the prone position and then, in the lateral position, en bloc resection was completed along with the lung resection (large wedge resection or lobectomy) and involved vertebral bodies. There was no immediate postoperative mortality. Three patients died during the follow-up period at the 6th, 8th, and 14th postoperative months with a postoperative recognized metastasis. The fourth patient was in follow-up at 20 months. Although T4N0M0 (vertebral involvement) lung cancers are considered inoperable, lung resection with hemivertebrectomy of the involved vertebra after neoadjuvant chemotherapy and radiotherapy is an alternative treatment in this type of lung cancer. Staging should be made meticulously for the expected surveillance.