[Surgical treatment of lung cancer with complete VATS lobectomy, new in the Netherlands]. / De chirurgische behandeling van longkanker via complete VATS-lobectomie, nieuw in Nederland.

* In view of the favourable results of lobectomy with complete 'video-assisted thoracoscopic surgery' (c-VATS) as described in literature, we started to perform these totally endoscopic lung resections in the Netherlands in March 2006. * Essential aspects of the procedure are that the ribs are not spread and that the procedure is performed using the image on the monitor only. * In the 23 c-VATS lobectomies performed, the advantages described in literature were confirmed. The operation was safe and entirely similar to the 'open' thoracotomy in an oncological sense. The effects for the patient were favourable. There was less pain after the operation, the function of the shoulder remained intact and the patients recovered rapidly. * It takes a considerable time before the learning curve reaches the plateau phase. The use of proper instruments is essential. * It is expected that the c-VATS lobectomy will be performed more often in the Netherlands in the coming years.

Influence of age, comorbidity and performance status on the choice of treatment for patients with non-small cell lung cancer; results of a population-based study.

BACKGROUND: In the Netherlands in 1997, 43% of patients with newly diagnosed lung cancer were over 70. Large age-specific differences in treatment exist. We examined whether age, comorbidity, performance status and pulmonary function influenced treatment. PATIENTS AND METHODS: Data on patients with newly diagnosed non-small cell lung cancer (N = 803) were obtained: comorbidity, performance status, pulmonary function (FEV1) and initial treatment. Age-specific differences in treatment according to the guidelines were examined. Odds ratios were calculated by means of logistic regression analyses. RESULTS: 82% with stage I or II disease received treatment according to the guidelines; this applied to 48% with stage IIIA disease and to 54% with stage IIIB disease. For all stages, this proportion decreased with increasing age. In stage IV disease, 36% did not receive any treatment; this applied to 52% of the elderly patients (75+ years). Multivariate analyses showed associations between comorbidity and treatment choice, but none with performance status. Age of 75+ years appeared to be the most important factor for not receiving treatment according to guidelines. CONCLUSION: A substantial proportion of elderly patients with non-small cell lung cancer did not receive standard treatment. Performance status and comorbidity seldom formed the underlying reason. Calendar rather than biological age seemed to play the most important role in choice of treatment for patients with non-small cell lung cancer.

[Sarcoma of the thoracic wall following mastitis radiotherapy 38 years previously]. / Sarcoom van de thoraxwand na radiotherapie voor mastitis 38 jaar eerder.

A 62-year-old woman presented with a feeling of pressure between her shoulder blades. Physical examination and laboratory test showed no abnormalities. Conventional X-ray of the thorax showed, by chance, a condensation of the second rib. CT scan showed a solitary lesion at the same location. Patient's history mentioned post-partum mastitis 38 years earlier, for which she was treated with X-ray therapy of about 4 to 5 Gray in 1 fraction. A partial rib resection was performed prior to diagnosis. The histopathological diagnosis was stage IA chondrosarcoma. It was excised in toto and an uneventful disease course ensued. In the past, X-ray therapy was used for many different benign diseases. Many doctors nowadays are not aware of this. This case illustrates that radiotherapy for benign disease can give rise to post irradiation sarcomas. Long-term follow-up of an irradiated region is essential for early diagnosis and may lead to higher cure rates.

Improved pre-operative mediastinal staging in non-small-cell lung cancer by serial sectioning and immunohistochemical staining of lymph-node biopsies.

OBJECTIVE: Mediastinal staging of non-small-cell lung carcinoma (NSCLC) by mediastinoscopy suffers from a low sensitivity, leading to a number of patients with unforeseen N2 disease at thoracotomy. This study was undertaken to assess whether pre-operative staging could be improved by serial sectioning and immunohistochemical staining of mediastinoscopy biopsies. METHODS: In 183 consecutive patients with NSCLC, a thoracotomy was performed after a thorough mediastinal staging by computed tomography scan and cervical mediastinoscopy. In 158 patients (88%), a mediastinal node dissection was performed, revealing unforeseen N2 disease in 24 cases (15%). The preserved mediastinoscopy biopsies of these patients were retrospectively serially sectioned and stained with MNF 116. RESULTS: Metastases could be identified in seven cases (30%), reducing unforeseen N2 disease from 15 to 10%. The number of patients who could theoretically benefit from neo-adjuvant therapy would have been increased by at least 10%. CONCLUSIONS: Pre-operative mediastinal staging can be improved considerably by serial sectioning and immunohistochemical staining of mediastinoscopic biopsy specimens.

Reduced E-cadherin expression is associated with increased lymph node metastasis and unfavorable prognosis in non-small cell lung cancer.

E-cadherin is a calcium-dependent, epithelial cell adhesion molecule whose reduced expression has been associated with tumor dedifferentiation and increased lymph node metastasis in clinical studies involving several carcinomas. In this study, 111 patients who had previously undergone complete resection and systematic mediastinal lymph node dissection for non-small cell lung cancer (NSCLC) were studied retrospectively. In the primary tumor, as well as in the lymph node metastases, E-cadherin expression was detected by immunohistochemistry using a monoclonal antibody (HECD-1; Takara, Otsu, Japan). There was a significant inverse correlation between E-cadherin expression and lymph node stage (Pearson correlation coefficient -0.52, p = 0.0001) as well as tumor differentiation (Pearson correlation coefficient -0.27, p = 0.005). Moreover, Kaplan and Meier survival estimates showed a significant correlation between E-cadherin expression and patient survival in log rank testing (p = 0.006). In the patient group with the highest proportion of E-cadherin positive tumor cells, 60% of the patients were still estimated to be alive at 36 mo, versus 32% of the patients in the group classified as showing negative E-cadherin expression. Our findings provide clinical evidence that reduced E-cadherin expression is associated with tumor dedifferentiation, increased lymphogenous metastasis and poor survival. It seems therefore that E-cadherin expression might be an important prognostic factor in NSCLC.

Transaxillary first rib resection for thoracic outlet syndrome.

Surgical therapy of thoracic outlet syndrome (T.O.S.) is highly controversial. In contrast to many large series, recent literature reports a moderate to poor outcome following surgery. The aim of the present study is to evaluate the efficacy of transaxillary first rib resection in the treatment of T.O.S. Over the past twelve years 106 first rib resections were performed on 92 patients. Neurological complaints predominate (63%), while arterial and venous symptoms account for 22 and 15% of the symptoms respectively. Preoperative screening consisted of a thorough interview and clinical examination, chest and spine X-ray, duplex-ultrasonography, angiography on indication, E.M.G. and a neurologist's consultation. Standard treatment was transaxillary first rib resection as described by Roos and Owens. Eighty-five patients (92%) attended a follow-up examination with a mean follow-up of 63.2 months. All patients were examined by an independent observer and the resumption of pre-illness activity was recorded. Only 52% of the operations turned out to be successful. All other procedures resulted in identical or worse complaints than before surgery. In contrast to many other series and in accordance with some recent critical series we conclude that first rib resection is often not effective in relieving T.O.S. A renewed focus on conservative treatment seems justified with surgery serving as a very last resort.

Intranodal and extranodal tumour growth in early metastasised non-small cell lung cancer: problems in histological diagnosis.

AIM: To question the observer reliability or agreement of reports on the intranodal and extranodal tumour growth patterns in early metastasised non-small cell lung cancer (NSCLC). METHODS: In a pilot study original histological sections of mediastinal lymph node metastases from NSCLC obtained by lymph node dissection (n = 82) or by mediastinoscopy (n = 62) were examined and classified independently by three pathologists as extranodal, intranodal, or indefinite. After clear criteria for these growth patterns had been defined sections were re-examined and recategorised one year later. Interobserver agreement was examined for both investigations. RESULTS: In the dissected lymph nodes the kappa value improved significantly from 0.52 (moderate agreement) at the first investigation to 0.72 (good agreement) at the second. In the mediastinoscopic lymph node biopsy specimens an increase in kappa value from 0.50 at the first to 0.67 at the second examination was found, although this improvement was not significant. In mediastinoscopic biopsy specimens a very high proportion of tissue samples showed indefinite tumour extension. CONCLUSION: Good reproducibility of intranodal and extranodal growth patterns in the histological examination of mediastinal lymph node metastases can be achieved, provided that pathologists use strictly defined criteria. In mediastinoscopic biopsy specimens it is often impossible to differentiate between intranodal and extranodal tumour growth.

Interobserver variability and accuracy of computed tomographic assessment of nodal status in lung cancer.

To assess the interobserver variability of computed tomography in determining nodal status in non-small cell lung carcinoma, four experienced radiologists reviewed the computed tomographic scans of 147 patients. Interobserver variability was calculated using the kappa statistic. In addition, the accuracy of CT assessment of the nodal status by the four observers was measured by comparing their findings with thorough mediastinal exploration at both mediastinoscopy (n = 35) and thoracotomy (n = 112). Interobserver variability was large between the four radiologists regarding nodal status on a per-patient basis (kappa = 0.38). Sensitivity of computed tomography for the observers on a per-patient basis ranged from 40% to 69% with a 1.0-cm criterion and from 28% to 56% with a 1.5-cm criterion. From the large interobserver variability and the low sensitivities in this study it can be concluded that a negative result of computed tomography regarding mediastinal lymph nodes does not eliminate the need for mediastinoscopy or exploration of the mediastinum at the time of operation in patients with non-small cell lung cancer.

Clinical significance of intranodal and extranodal growth in lymph node metastases of non-small cell lung cancer.

In non-small cell lung cancer with mediastinal lymph node metastasis, intranodal growth is regarded as prognostically more favourable than extranodal growth. We evaluated the clinical implications. Mediastinal lymph node metastases removed at mediastinoscopy and/or surgery were classified as intranodal, extranodal or indefinite. "Minimal N2 disease" denoted a solitary, intranodal metastasis, "extranodal" at least one extranodal lymph node metastasis, and "indefinite" more than one intranodal or at least one indefinite metastasis. Although in patients with resected N2 disease, c. 21% of the nodal metastases were "indefinite", survival was significantly better in minimal N2 disease than in the combined groups with extranodal and indefinite lymph node metastases. Of the metastatic nodes removed at mediastinoscopy, 75% were unsuitable for definite classification as only intranodal or extranodal. Only 1 of 49 patients had purely intranodal N2 disease. Thus, it was seldom feasible to classify mediastinoscopic lymph node involvement as intranodal or extranodal, and this classification is unhelpful as regards decisions on thoracotomy. However, when nodal involvement in resected N2 disease was limited to a single node with intranodal growth, the prognosis was better than in patients with extranodal disease or more than one intranodal metastasis or indefinite nodes.

Lipoma of the external thoracic wall.

We report the case history of an external thoracic wall lipoma, which was noticed incidentally on a chest roentgenogram because of its calcification. A probable diagnosis was made by computer tomography. Because of the increase in size of the tumour it was removed surgically, but no evidence of malignant degeneration was found.

[Good results of subfascial endoscopy as treatment of communicating vein insufficiency]. / Goede resultaten van subfasciale endoscopie als behandeling van insufficiënte Vv. perforantes.

Incompetent communicating or perforating veins are often responsible for recurrent varicose veins with skin changes at the lower leg, especially in the postthrombotic syndrome. Subcutaneous and subfascial surgical explorations carry a 35% complication rate. We used a new endoscopic technique to locate and ligate communicating veins with the objective to decrease this complication rate. Through a short skin incision on the anteromedial side of the proximal 1/3 of the lower leg the fascia is incised over 2 cm and the subfascial space opened by finger dissection. A mediastinoscope (length 18 cm; diameter 12 mm) is inserted and pushed down beneath the fascia to the level of the malleolus. Under direct vision the communicating veins crossing this space are located and ligated with haemoclips. In 48 patients, 15 male and 33 female, with a mean age of 53 (22-73) years, 54 legs were treated: 40 legs showed recurrent varicose veins, due to incompetent communicating veins with severe skin changes and ulcers, and 14 had primary varicosis. All patients complained of fatigue and pain. In 49 legs (44 patients) relief of preoperative complaints was obtained and in 5 (4 patients) there was no change. Two indurated wounds and 1 dehiscent wound were treated conservatively. One patient, operated on both legs, developed a severe subfascial infection on both sides necessitating a reintervention. The advantages of the subfascial endoscopic technique, a fast operative procedure, fewer postoperative wound infections (9.3%), a good cosmetic effect, and a low (2.5% after 3.8 years) recurrent ulcer rate make it a valuable new method for treating incompetent communicating veins.

"Asymptomatic" ruptured aneurysm: a report of two cases of aortocaval fistula presenting with cardiac failure.

Two cases of aortocaval fistula are described in patients with an otherwise asymptomatic abdominal aortic aneurysm. Both presented because of cardiac symptoms, one with chest pain and acute heart failure and electrocardiogram signs of acute coronary ischaemia, the other with a long history of chronic cardiac failure resistant to therapy. In the first case the fistula was proven by means of a CAT scan. Positive proof of a fistula or leakage is important because asymptomatic aneurysms should not be operated on in cardiac compromised patients. On the other hand, if an aortocaval fistula is present, operation is necessary to prevent fatal cardiac failure.

Mediastinal lymph node dissection in resected lung cancer: morbidity and accuracy of staging.

A study was performed to investigate the morbidity of mediastinal lymph node dissection (MND) and to establish its contribution to the accuracy of staging in surgically treated non-small cell lung cancer. Between 1988 and the middle of 1991 a systematic sampling of mediastinal lymph nodes was done in 20 patients and a MND was carried out in 65 patients. Data from these patients were compared with those from a control group of 70 patients operated on in 1986 and 1987, who would have had MND if they had been treated in the years after 1988. The groups were comparable according to important clinical characteristics. There was a significantly greater fluid production via the drains in the groups with systematic sampling and MND, compared with the controls. Volume of blood lost during the operation and number of units blood transfused perioperatively were not significantly different between the groups. Three lesions of the recurrent laryngeal nerve and two episodes of chylothorax were observed, all probably caused by MND. The discovery ratio for N2 disease in the MND and systematic sampling groups together compared with the control group was 2.1, with a 95% confidence interval from 1.04 to 4.2.

Tumor embolus in lung surgery. A case report and review of the literature.

A 71-year-old man underwent a completion pneumonectomy for a recurrent carcinosarcoma of the left upper lobe. A single lumen endotracheal tube was used for intubation. During dissection the right main bronchus became blocked by a tumor mass. Due to severe adhesions it was impossible to open the airway from inside the operation field. This neither was also not possible by bronchoscopic maneuvers and the patient died. The case is similar to six cases described in the literature since 1966 [4-7, 9, 10]. Recommendations for preventing and treating the complications are given.

Proliferating cell nuclear antigen (PCNA) expression in formalin-fixed tissue of non-small cell lung carcinoma.

An immunohistochemical study of non-small cell lung carcinoma using PC10, a monoclonal antibody against PCNA, was performed on tissues routinely processed with formalin fixation and paraffin embedding. The PCNA labelling index and mitotic index were determined from sections of these tissues. Tumours showed a high mean PCNA labelling index of 53.3%. The mean mitotic index was 10.3/1000 cells. Inter-examiner agreement of mitotic counting was good. A linear correlation between the PCNA labelling index and mitotic index was demonstrated (r = 0.71, P less than 0.00001). It is concluded that immunohistochemical nuclear labelling with anti-PCNA on routinely processed tissue is a simple technique for the assessment of proliferation in non-small cell lung carcinoma.

Accuracy of computed tomography of the mediastinum in bronchogenic carcinoma.

The results of preoperative CT-scanning were compared with the pathological findings in lymph-nodes taken at mediastinoscopy and/or thoracotomy in 144 patients to determine the accuracy of CT of the mediastinum in staging lung cancer. Ninety-nine patients had squamous cell carcinoma, 31 adenocarcinoma, nine undifferentiated large-cell carcinoma and five patients had carcinoma of a mixed cellular type. Mediastinoscopy was done in 105 patients and thoracotomy in 126. The results of our study showed that CT is useful to select patients for mediastinoscopy for T1 lung cancer in general because of a negative predictive value of 98 per cent. CT is also useful for T2 and T3 lung cancer located at the left lower lobe or the right upper, middle or lower lobe (negative predictive value 87%). However, mediastinoscopy is always necessary in patients with T2 or T3 lung cancer at a main bronchus or a left upper lobe because of the low negative predictive value (58%). Preoperative aorto-pulmonary window evaluation is not recommended in case the CT-scan for the aortopulmonary window is negative because of a reasonable negative predictive value (81%).

The imaging quality of angiodynography in the ilio-femoral tract.

The imaging quality of angiodynography (Quantum; Philips) in the ilio-femoral tract was compared with uniplanar angiography. One hundred ilio-femoral tracts were investigated with both translumbar conventional angiography and angiodynography. The ilio-femoral tract was divided into five parts; proximal and distal common iliac, proximal and distal external iliac and common femoral. Stenosis was scored from 0-24, 25-49, 50-74, 75-99 and 100% and the lengths of those of 25% or more were measured in centimeters. Because the thickness of the subcutaneous fat layer decreases the depth range (normally 11.5 cm) of the 5.0 MHz transducer it was also measured in centimetres. The results showed that a significantly larger number of vessels were not seen (especially the common iliac) with an increasing thickness of the subcutaneous fat. The results based on the real-time imaging quality alone of angiodynography showed a reasonable accuracy of 83.9% when detecting stenoses graded from 0-24, 25-49, 50-74, 75-99 up to 100%. The clinically more important discrimination between a haemodynamically important stenosis of more than 50% showed a sensitivity of 88% and specificity of 98% on visual information alone. By integrating the peak velocity measurements to the results, this sensitivity rose to 95% and the specificity became 99%. The correlation in length was within a range of 1 cm in 94% and within 1-2 cm in 6% of the stenoses. In conclusion, angiodynography is a reliable technique for investigating the ilio-femoral tract.