Malignant pleural effusion and talc pleurodesis. Experimental model regarding early kinetics of talc particle dissemination in the chest after experimental talc pleurodesis.

PURPOSE: Talc remains a commonly used agent for pleurodesis malignant pleural effusion. Nevertheless, it is associated with a 3-9% incidence of pulmonary reactions ranging from simple pneumonitis to acute respiratory distress syndrome (ARDS). The underlying lung pathology and the size and rate of talc particle dissemination have been implicated as the cause of these complications. There seems to be an acknowledged lack of evidence regarding detailed very early intrathoracic talc particle migration. MATERIALS AND METHODS: Thirty white male New Zealand rabbits underwent experimental pleurodesis and were randomly assigned to 3 (A, B, C) study groups (10 in each group). Rabbits were sacrificed 6, 12 and 18 h after talc administration. Samples from both lungs, mediastinum and parietal pleura were obtained. The number of talc crystals (m) deposited was counted and averaged along all slices of the various tissue samples. RESULTS: A high degree of early talc deposition and subsequent epithelial injury in all examined tissues was observed. Diffuse talc deposition occurred in both lungs, but in a different manner. On the side of talc administration, talc particles were deposited in a time-dependent fashion. On the contralateral side, talc was rapidly deposited during the first hours after the procedure, then the rate of deposition decreased, and increased again between 12 and 18 h after the procedure. CONCLUSION: Large-sized talc particles are deposited on both lungs very early after pleurodesis. At the same time inflammatory pulmonary changes appear bilaterally. Despite contradicting data in the literature, these findings should always be kept in mind when performing this procedure in high risk patients.

Does anemia affect outcome after lobectomy or pneumonectomy in early stage lung cancer patients who have not received neo-adjuvant treatment?

BACKGROUND: Preoperative anemia has been shown to be an ominous prognostic factor for survival in patients with early stage non small cell lung cancer. METHODS: Two hundred and fourteen patients underwent resection for early stage non small cell lung cancer between 2001 and 2006 without neo-adjuvant treatment. Patients were divided into four groups based on their admission hemoglobin (Hgb): group I: Hgb < or = 12 g/dl, group II: Hgb = 12.1 - 12.9 g/dl, group III: Hgb = 13.0 - 14.0 g/dl, and group IV: Hgb > 14 g/dl. Cox regression analysis was used to evaluate each variable's impact on midterm survival taking all causes and lung cancer-specific mortality into account. Kaplan-Meier survival plots were estimated. RESULTS: Preoperative hemoglobin (HR = 1.44, 95 % confidence intervals 1.08 - 1.94, P = 0.014) and pneumonectomy (HR = 3.58, 95 % confidence intervals 1.26 - 10.16, P = 0.017) were the only predictors of all-cause midterm mortality. Similarly, when only lung cancer-related mortality was considered, preoperative hemoglobin (HR = 1.81, 95 % confidence intervals 1.17 - 2.78, P = 0.007) and pneumonectomy (HR = 6.89, 95 % confidence intervals 2.29 - 20.73, P = 0.001,) were independent predictors. Age, gender, pulmonary function test results, tumor stage, and histology did not influence survival. CONCLUSIONS: Preoperative anemia and the type of resection in early stage non small cell lung cancer have an impact on midterm survival and lung cancer-specific mortality.

Independent predictors for early and midterm mortality after thoracic surgery.

BACKGROUND: The purpose of the present study was to determine independent predictors for early and midterm mortality for the whole context of thoracic surgery. METHODS: We studied 1453 consecutive patients who underwent thoracic surgery between 2002 and 2005. Operations included lung resections (n = 504), mediastinal (n = 468), pleural and pericardial (n = 226), esophageal (n = 83), chest wall (n = 85), tracheal (n = 50) and other procedures (n = 37). Midterm survival data (mean follow-up 2.0 +/- 1.1 years) were obtained from the National Death Index. Multivariate logistic regression was used to assess in-hospital mortality. Independent predictors for midterm mortality were determined by multivariate Cox regression analysis. RESULTS: There were 47 (3.2 %) in-hospital and 312 (21.5 %) late deaths. Independent predictors for in-hospital mortality included Zubrod score (OR 2.72, P < 0.001), ASA score (OR 3.42, P < 0.001), pneumonectomy (OR 20.71, P = 0.001) and no history of cerebrovascular events (OR 0.27, P = 0.011). Independent predictors for midterm mortality included age (HR 1.03, P < 0.001), weight loss (HR 1.57, P = 0.005), Zubrod score (HR 1.47, P < 0.001), primary lung cancer (HR 1.98 P < 0.001), intrathoracic extrapulmonary metastases (HR 2.78, P < 0.001), primary chest wall tumor (HR 0.14, P = 0.008), diabetes requiring insulin (HR 1.71, P = 0.017), no preoperative renal failure (HR 0.57, P = 0.004), no comorbidities (HR 0.54, P = 0.009), ASA score (HR 1.69, P < 0.001), postoperative radiation treatment (HR 1.90, P = 0.016), pneumonectomy (HR 2.18, P = 0.040), reoperation for bleeding and/or postoperative transfusion (HR 3.10, P = 0.027) and postoperative pulmonary complications (HR 1.89, P = 0.013). CONCLUSIONS: We determined independent predictors for in-hospital and midterm mortality for the whole context of thoracic surgery. Zubrod and ASA scores affect both early and midterm mortality.

Multimodality treatment of neuroendocrine tumors of the thymus.

BACKGROUND: Neuroendocrine tumors of the thymus are rare neoplasms. Four patients with this tumor who underwent multimodality treatment are presented and the literature is briefly reviewed. METHODS: The medical records of all patients treated for neuroendocrine tumors of the thymus from 1979 to 2002 were reviewed. Tumors were classified using a slight modification of the World Health Organization criteria. RESULTS: The patients' median age was 38 years. All patients underwent extensive excision of the tumor. Histological diagnosis was atypical carcinoid (2), typical carcinoid (1), and small cell carcinoma (1). All patients developed recurrence(s). One patient died 132 months after diagnosis. The remaining three patients are alive with no symptoms at 135, 99, and 35 months, respectively, after diagnosis. Two patients with recurrences have been on treatment with Octreotide LAR with satisfactory results. One patient is free of disease. CONCLUSIONS: Neuroendocrine tumors of the thymus are potentially aggressive tumors. Radical resection is the treatment of choice. The encouraging results obtained by administration of Octreotide LAR in two of our patients warrant further investigation.

Presternal gastric bypass for late postpneumonectomy esophagopleural fistula.

SUMMARY: A 71-year-old diabetic patient underwent right pneumonectomy with wide mediastinal lymph node dissection for lung cancer (right upper lobe). Postoperatively he developed pleura empyema that was successfully treated - drainage and Eloesser window, followed by adjuvant radiotherapy. Two months later he developed an esophagopleural fistula. Due to the patient's physical condition primary repair of the esophageal rupture was considered a high-risk operation. Stenting was also considered as inappropriate due to the existing contamination. Bypassing with the use of the stomach as conduit was preferred due to its simplicity compared to the colon. In order to avoid mediastinum after the postradiation alterations and because of the Eloesser window we adopted a presternal subcutaneous position. Twenty-eight months after the by pass procedure the patient is in good health being able to eat and drink, has gained weight and shows no evidence of malignancy. Presternal gastric esophageal bypass has never been reported as a treatment for esophagopleural fistula. This case report indicates its possible successful use in this debilitating setting, although more experience is needed.

Pleuropulmonary blastoma in childhood. A malignant degeneration of pulmonary cysts.

Pleuropulmonary blastoma (PPB) is an extremely rare intrathoracic neoplasm of early childhood with an unfavorable outcome. In this article, two children with PPB associated with pre-existing pulmonary cysts are presented. It is emphasized that surgical excision is the treatment of choice for all pulmonary cysts.

Pyothorax-associated lymphoma (PAL): a western case with marked angiocentricity and review of the literature.

AIMS: To report a case of pyothorax-associated lymphoma in a non-immunocompromised 78-year-old man with a 45-year history of tuberculous pleuritis and left pleural effusion. Pyothorax-associated lymphoma is a high-grade non-Hodgkin's lymphoma occurring in 2% of patients with long-standing tuberculous pleuritis and pyothorax. Pyothorax-associated lymphoma is frequently Epstein-Barr virus (EBV)-associated, mainly reported in Japan but exceedingly rare in western countries. METHODS AND RESULTS: Histology revealed a high-grade, diffuse large B-cell lymphoma with immunoblastic and plasmacytoid features and marked angiocentricity with focal destruction of the vessel walls. Immunohistochemistry revealed a post germinal B-cell phenotype. RNA in-situ hybridization and molecular analysis showed a latent EBV infection and absence of human herpes virus-8 (HHV-8). CONCLUSIONS: Pyothorax-associated lymphoma represents a rare but distinctive type of diffuse large B-cell lymphoma, with characteristic clinico-epidemiological, immunohistological, and biological features.

Immunohistochemical localization of c-mos at the light and electron microscope level in non-small cell lung carcinomas.

C-mos is a cytoplasmic upstream activator of the mitogen-activating protein kinase pathway with serine-threonine kinase activity. It plays a well established and vital role in oocyte maturation by participating in metaphase II arrest and meiotic asymmetric division, but little is known about its function in somatic cells. Recently, we observed overexpressed c-mos in a portion of non-small cell lung carcinomas (NSCLCS). In particular, c-mos immunoreactivity was detected in tumor cell nuclei in addition to its expected cytoplasmic localization, and c-mos overexpression was associated with chromosomal instability among other findings. To verify our earlier observations and to clarify further the role of c-mos in NSCLCS, we examined its distribution by both light and electron microscopy. We detected c-mos in the cytoplasm and/or nucleus of a portion of tumor cells and fibroblasts. In particular, granular immunoreactivity was observed in the cytoplasm closely associated with the rough endoplasmic reticulum. Nuclear staining was confirmed and was often found near the nuclear membrane, as well as in some large multilobular, possibly aneuploid, nuclei. C-mos positivity was also found in the nuclei of tumor cells undergoing apoptosis. Furthermore, c-mos was detected in areas with diminished vascularization. It should be noted that nuclear staining was found at the ultrastructural level more extensively than at the light microscope study. This suggests a masking effect by the hematoxylin nuclear counterstain.

Central venous and mixed venous oxygen saturation in critically ill patients.

BACKGROUND: Although mixed venous O2 saturation (SvO2) accurately indicates the balance of O2 supply/demand and provides an index of tissue oxygenation, the use of a pulmonary artery (PA) catheter is associated with significant costs, risks and complications. Central venous O2 saturation (ScvO2), obtained in a less risky and costly manner, can be an attractive alternative to SvO2. OBJECTIVES: To investigate whether the values of ScvO2 and SvO2 are well correlated and interchangeable in the evaluation of critically ill ICU patients and to create an equation that could estimate SvO2 from ScvO2. METHODS: Sixty-one mechanically ventilated patients were catheterized upon admission and ScvO2 and SvO2 values were simultaneously measured in the lower part of the superior vena cava and PA respectively. RESULTS: SvO2 was 68.6 +/- 1.2% (mean +/- SEM) and ScvO2 was 69.4 +/- 1.1%. The difference is statistically significant (p < 0.03). The correlation coefficient r is 0.945 for the total population, 0.937 and 0.950 in surgical and medical patients, respectively. In 90.2% of patients the difference was <5%. When regression analysis was performed, among 11 models tested, power model [SvO2 = b0(ScvO2)b1] best described the relationship between the two parameters (R2 = 0.917). CONCLUSIONS: ScvO2 and SvO2 are closely related and are interchangeable for the initial evaluation of critically ill patients even if cardiac indices are different. SvO2 can be estimated with great accuracy by ScvO2 in 92% of the patients using a power model.

An alternative approach for the surgical management of hydatid disease of the liver.

Hydatid disease of the liver still remains a serious medical problem. As a result of increased travelling and immigration, it has also appeared in previously unaffected countries and is now well manifested in countries where the medical personnel lack the experience to treat this problem. We report an alternative method for the surgical management of hydatid disease of the liver, especially that located over the right superior-posterior aspect of the liver. Through a lateral right thoracotomy, we have a better exposure of the cyst and by using the right hemidiaphragm we achieve the same beneficial effect as omentoplasty does.

Case report. Successful treatment of two cases of post-surgical sternal osteomyelitis, due to Candida krusei and Candida albicans, respectively, with high doses of triazoles (fluconazole, itraconazole).

Two female patients, aged 75 and 59 years, respectively, with candidal sternal osteomyelitis were successfully treated by the administration of triazoles. Both had developed post-operative wound infection after sternotomy for coronary artery by-pass grafting. Sternal osteomyelitis was confirmed by bone scans with technetium 99Tc and gallium 67Ga. The cultures, from the pus draining at the site of the sternotomy scar, grew Candida krusei in the first case. The fistula closed after a 9-week course of itraconazole therapy (800 mg daily, followed by 600 mg daily) and the patient completed a 6-month period of therapy. The second patient had underlying diabetes mellitus. Post-operatively she developed two fistulae draining pus on the sternum. The pus cultures grew C. albicans. Initial treatment with oral fluconazole (400 mg daily) failed. Subsequent treatment with liposomal amphotericin B also failed. A dramatic improvement was noted when the patient received high doses of fluconazole (800 mg daily). The fistulae gradually closed after 1 month. Oral fluconazole was continued for 6 months. The cure was confirmed by bone scans. Three years later, both patients remained well.

Blunt and penetrating trauma of the thoracic aorta and aortic arch branches: an autopsy study.

BACKGROUND: Due to the highly lethal nature of trauma of the thoracic aorta and aortic arch branches (TA-AAB), autopsy studies are essential for the investigation of its epidemiologic characteristics. METHODS: The reports of 11,446 consecutive medicolegal autopsies were reviewed. Among 1,980 injury-related fatalities, 251 victims (12.7%) with 302 TA-AAB injuries were found. Several trauma variables were recorded and their relations were examined. RESULTS: Blunt TA-AAB injuries were recorded in 86.4% of the victims. They were located mainly at the aortic isthmus and distal descending thoracic aorta and were accompanied to a great extent by extrathoracic trauma. The vast majority of penetrating lacerations were located at the ascending aorta, arch, and arch branches and were mostly associated with other lethal intrathoracic injuries. All penetrating trauma victims died before reaching the hospital, whereas 5.5% of the blunt trauma victims were admitted to the hospital alive. CONCLUSION: Major differences between blunt and penetrating TA-AAB injuries were revealed, regarding their location, patterns of concomitant injuries, and victims' survival time. Patients injured in motor vehicle crashes, as opposed to various other causes of trauma, were found to have the best chances of reaching the hospital alive.

A phase II study of paclitaxel-ifosfamide-cisplatin combination in advanced nonsmall cell lung carcinoma.

BACKGROUND: The necessity to develop more effective chemotherapy regimens in advanced nonsmall cell lung carcinoma (NSCLC) prompted the authors to evaluate the paclitaxel-ifosfamide-cisplatin (PIC) combination, developed on the basis of high individual single-agent activity, in vitro synergism, and tolerance as determined in a previous Phase I study by the authors. PATIENTS: Eligibility criteria included advanced NSCLC (American Joint Committee on Cancer [AJCC]/International Union Against Cancer [UICC] Stage III/IV), Eastern Cooperative Oncology Group performance status (PS) /= 10,000/microL. RESULTS: Fifty patients were entered, and all were evaluable for response and toxicity: median age, 58 years (range, 40-72), PS, 1 (range, 0-2), Gender: 44 males and 6 females, Stages IIIA, 6 patients; IIIB, 17; IV, 27; histologies: adenocarcinoma, 27 patients; squamous, 17; large cells, 5; unspecified, 1. Metastatic sites at diagnosis included lymph nodes, 33 patients; bone, 6; liver, 5; brain, 10; lung nodules, 7; adrenals, 6; other, 2. Thirty-two of 50 (64%; confidence interval, 50.7-77.3%) evaluable patients responded: 4 complete remissions, 28 partial remissions, 13 stable disease, and 5 progressive disease. The quality-of-life score improved in 37 of 50 (74%) patients. The median response duration was 7 months (range 2-34+); median time-to-progression, 8 months (range, 1-36+), median overall survival, 12 months (range, 2-36+). One-year survival was 53%. Grade 3 and 4 toxicities included neutropenia 38 of 50 patients with 21 developing Grade 4 neutropenia (

Effect of impaired vasa vasorum flow on the structure and mechanics of the thoracic aorta: implications for the pathogenesis of aortic dissection.

OBJECTIVE: To investigate the alterations of structure and mechanical properties of the aortic wall, resulting from impairment of vasa vasorum flow. METHODS: Eight healthy Landrace pigs were subjected to interruption of vasa vasorum flow to the upper segment of their descending thoracic aorta. Under sterile conditions, the periaortic tissue was excised and the contiguous intercostal arteries were ligated. Ten sham-operated pigs were used as controls. Fifteen days postoperatively, the animals were sacrificed and their upper descending thoracic aortas were removed. Histology, and collagen and elastin content determination by image analysis technique were performed. Mechanical analysis of aortic strips was carried out with a uniaxial tension device and stress-strain curves were obtained. RESULTS: In contrast to normal aortic walls of the control group, histology of the avascular aortas revealed severe ischemic necrosis of the outer media along with abnormal straightening of the elastin and collagen fibers, without significant collagen and elastin content changes. The borderline between the outer ischemic and inner non-ischemic media was sharp, and an outset of dissection was observed at this point. Mechanical analysis showed that at the same level of strain, the ischemic aorta was significantly stiffer at both low (P=0.03) and high strains (P=0. 003). CONCLUSIONS: Impairment of blood supply to the thoracic aorta leads to abnormal morphology of elastin and collagen fibers of the outer media, resulting in increased aortic stiffness under a wide range of stresses. In the clinical setting, decreased vasa vasorum flow, reportedly occurring in arterial hypertension, may increase the stiffness of the outer media of the thoracic aorta and produce interlaminar shear stresses, contributing to the development of aortic dissection.

Surgical treatment for lung hydatid disease.

Lung is the second most common site for hydatid disease after the liver. The aim of this study is to present the clinical symptomatology, diagnostic evaluation, and surgical techniques for the treatment of lung hydatid disease. During the last 25 years, 42 patients with lung hydatid cysts were treated surgically in our department. In four patients there were cysts in the liver and in one case in the spleen. The cysts were located in the right lung in 16 patients (38%), in the left lung in 23 patients (54.8%), and in both lungs in 3 patients (7.14%). Eighteen patients (42.9%) presented with complications: suppuration in one patient (2.4%), rupture to the bronchial tree in 16 patients (38%), and pneumothorax in one patient (2.4%). Diagnosis was established preoperatively in all cases; chest radiography and computed tomography were most helpful for diagnosis. Forty-six operations were performed in 42 patients; three patients with bilateral cysts underwent staged thoracotomies, and one patient was reoperated for recurrent disease. All cases were managed surgically, with several types of radical (34 cases) or conservative (12 cases) procedures. Radical procedures were lobectomy and rarely pneumonectomy, which were used more often during the first half of the study period. Cystectomy with capitonnage, the most commonly performed conservative procedure, was mainly used during the second half of the study period. Postoperative morbidity was 15.2% and the 30-day mortality rate was 0%. In one case there was postoperative hemorrhage that required reexploration. The median hospital stay for uncomplicated cases was 12 days and for complicated cases 21 days. In conclusion, pulmonary hydatidosis often presents with complications requiring emergency surgery. A lung-conserving operation is the treatment of choice for lung hydatid disease and offers a good surgical outcome with a minimal recurrence rate.

p53 and bcl-2 protein expression in non-small-cell lung carcinoma.

The diagnostic significance of p53 and bcl-2 proteins in epithelial non-small-cell lung cancers was examined, and the relationship between these proteins expression and other disease parameters, including stage of the disease and tumor differentiation, were studied. We analyzed p53 and bcl-2 proteins expression in 60 imprint smears of freshly resected lung tumors (37 squamous and 23 adenocarcinomas) using the immunocytochemical technique. There were seven patients with stage I disease, 24 with stage II, 23 with stage IIIa, and six with stage IIIb disease, according to the International Staging System classification. Sixteen of the tumors were bcl-2 positive and 25 were p53 positive. Twenty tumors were negative for both bcl-2 and p53 (33.3%). Statistical analysis showed no association between the incidence of p53 or bcl-2 positivity. Adenocarcinoma or squamous carcinoma analysis showed significant associations between p53 positivity and poor differentiation and advanced disease stage as well as bcl-2 and early disease stage and well-differentiated tumors. There was also an association between the stage of the disease and the degree of differentiation of the tumors. In conclusion, bcl-2 positivity must be considered a good prognostic sign. On the other hand, p53 positivity seems to indicate, even in tumors at a relatively early stage, that a serious aggressive tumor which will not be easily eradicated is present.

Primary desmoid tumor of the posterior mediastinum.

We describe a unique case of a de novo desmoid tumor of the posterior mediastinum in a 21-year-old nulligravida. The tumor recurred twice despite its histologically confirmed radical extirpations. Because of the aggressive local behavior of desmoid tumors and their unusual locations, which prevent wide excision margins, we favor the early consideration of adjuvant therapy.