Clinical significance of epithelial-mesenchymal transition-related markers expression in the micrometastatic sentinel lymph node of NSCLC.

OBJECTIVES: Metastatic lymph node affectation is the main prognostic factor in localised lung cancer. However, the pathological study of lymph nodes reveals tumour relapse for 20% of patients after oncological curative surgery. Recently, EMT (epithelial-mesenchymal transition) has been established as one of the main factors related to lymphatic dissemination and metastasis. This study evaluated the prognostic value of EMT-related gene expression in micrometastatic sentinel lymph nodes (SLN) of non-small cell lung cancer (NSCLC) patients. METHODS: The presence of genes CDH1, CDH2, VIM, TWIST1, SNAI1, SNAI2, ZEB1, and ZEB2 in mRNA was analysed in tumours and in the SLN of NSCLC patients for whom surgery was planned for treatment. The significant association between the expression level of EMT-related markers and patients' clinicopathological characteristics and relapse was assessed. RESULTS: Of the 96 patients, 56 (58.33%) presented molecular micrometastasis in SLN, which showed higher CDH1, CDH2, and VIM expressions than non-micrometastatic ones. An association linking a low CDH1/CDH2 ratio in SLN with molecular micrometastasis, adenocarcinoma, and non-smoking patients was found. The multivariate Cox regression analysis proved the prognostic accuracy of the CDH1/CDH2 ratio in SLN. CONCLUSIONS: The molecular EMT status of SLN could be used as an independent prognosis predictor in early stage NSLCL patients, and as a new tool to better stratify and predict patient outcomes.

Etiología de la mastitis crónica: propuesta de secuencia diagnóstica / Proposed diagnosis sequence for chronic mastitis aetiology

Introducción: Las lesiones inflamatorias mamarias precisan con frecuencia de estudio histopatológico por su capacidad de imitar a los tumores mamarios malignos. El objetivo es proponer una secuencia diagnóstica de las inflamaciones mamarias benignas crónicas. Material y método: Se han revisado en la literatura los métodos y algoritmos diagnósticos de las mastitis crónicas. Resultados: Se propone un algoritmo diagnóstico para los procesos inflamatorios crónicos mamarios. Requiere determinar el patrón histopatológico inflamatorio y su localización, así como un estudio microbiológico apropiado. Posteriormente puede precisar de nuevas pruebas bioquímicas y serológicas orientadas por una correlación clinicopatológica para establecer un diagnóstico específico. Discusión: No se han identificado en la literatura otros algoritmos diagnósticos avalados por estudios de alto nivel de evidencia. Los patrones histopatológicos no son uniformes. Conclusiones: El diagnóstico etiológico precisa identificar patrones histopatológicos inflamatorios benignos y su localización, un estudio microbiológico y pruebas orientadas por correlación clinicopatológica. Se precisan estudios de investigación con niveles de evidencia altos

Introduction: Inflammatory breast lesions require histopathological study due to their ability to clinically and radiologically mimic malignant mammary tumours. The objective is to propose a diagnostic technique for benign chronic inflammatory processes of the breast. Material and methods: We reviewed the literature on the diagnostic methods used in chronic mastitis. Results: We propose a diagnostic algorithm for chronic inflammatory processes of the breast. The aetiological diagnosis requires identifying benign inflammatory histopathologic patterns and locations, and microbiological study. New biochemical and serological tests oriented by clinicopathological correlation may then be required to establish a specific diagnosis. Discussion: No diagnostic algorithms based on studies with a high level of evidence have been identified. No uniformity in histopathologic patterns has been described. Conclusions: The etiologic diagnosis requires identifying benign inflammatory histopathologic patterns and locations, microbiological study and tests oriented by clinicopathological correlation. There is a lack of studies with a high level of evidence

Topography of the sentinel node according to the affected lobe in lung cancer.

PURPOSE: The objective of this study is to describe the anatomic location of the sentinel lymph node (SLN) of patients with lung carcinoma and to analyze its relationship with the characteristics of the tumor. PATIENTS AND METHODS: 98 Stage I lung cancer patients were included in the study. SLN was marked just after performing the thoracotomy by injecting peritumorally 0.25 mCi of nanocolloid of albumin (Nanocol1) labeled with Tc-99 m in 0.3 ml, and later, it was resected. For SLN micrometastasis analysis, CEACAM5, BPIFA1, and CK7 gene expression at mRNA level was studied. Possible relation between tumor characteristics and SLN location was analyzed. RESULTS: While most of the SLN were located in hilar area, we find a significantly higher number of SLN located in mediastinal stations when the lesion is in the left upper lobe (LUL). This difference disappears in the group of SLN with a positive result in the micrometastasis study. Regarding tumor size, squamous tumors and tumors located in the left lower lobe (LLL) were found significantly larger. CONCLUSION: The location of the SLN in patients with stage I lung cancer is predominantly hilar, being less consistent in the left hemithorax. The tumor size or histological type is not variables that affect this distribution. The distribution of SLNs with a positive result in the analysis of micrometastasis suggests further spread to the hilar areas when the lesion is in the LUL and to the mediastinal zones when it is in the LLL.

Study of survival in patients with malignant lung lesions treated with radiofrequency

OBJECTIVE: To report on the survival of a series of patients with primary and metastatic lung tumours treated with radiofrequency (RF). Four years ago we published our preliminary experience with the use of this technique. MATERIALS AND METHODS: For a period of 8 years we have treated 59 patients (by means of a total of 70 procedures) with primary or metastatic pulmonary neoplastic lesions, which fulfilled inclusion criteria to perform the technique. They were in all cases non-surgical lesions that had been either previously treated or not. The technique was performed in the radiology suite, under conscious analgo-sedation. We treated primary pulmonary lesions, neoplastic recurrences, or metastases with curative or palliative intention (pain management). RESULTS: Current global survival rate is 19 patients (32 %) with a mean of 26.61 ± 3.17 months (range: 20.38 ± 32.83) and a median of 16.00 ± 3.57 (range: 8.99-23.00). If we establish the difference between primary and metastatic tumours, mean survival is 27.62 ± 4.12 months in primary tumours (median: 16.00) vs. 24.65 ± 4.47 months in metastatic tumours (median: 16.00). When we studied the survival in those cases with a curative intent, mean survival in primary tumours was 30.97 ± 4.57 months (median: 21.00) vs. 25.14 ± 4.68 (median: 16.00) months in metastatic tumours. CONCLUSIONS: RF ablation of lung lesions is a minimally invasive procedure that is useful in primary tumours (especially in stage I) and metastatic ones. RF has proven its usefulness in the multidisciplinary treatment of this pathology due to the low incidence of serious complications and survival obtained, considering that patients are elderly with significant comorbidity (AU)

Study of survival in patients with malignant lung lesions treated with radiofrequency.

OBJECTIVE: To report on the survival of a series of patients with primary and metastatic lung tumours treated with radiofrequency (RF). Four years ago we published our preliminary experience with the use of this technique. MATERIALS AND METHODS: For a period of 8 years we have treated 59 patients (by means of a total of 70 procedures) with primary or metastatic pulmonary neoplastic lesions, which fulfilled inclusion criteria to perform the technique. They were in all cases non-surgical lesions that had been either previously treated or not. The technique was performed in the radiology suite, under conscious analgo-sedation. We treated primary pulmonary lesions, neoplastic recurrences, or metastases with curative or palliative intention (pain management). RESULTS: Current global survival rate is 19 patients (32 %) with a mean of 26.61 ± 3.17 months (range: 20.38 ± 32.83) and a median of 16.00 ± 3.57 (range: 8.99-23.00). If we establish the difference between primary and metastatic tumours, mean survival is 27.62 ± 4.12 months in primary tumours (median: 16.00) vs. 24.65 ± 4.47 months in metastatic tumours (median: 16.00). When we studied the survival in those cases with a curative intent, mean survival in primary tumours was 30.97 ± 4.57 months (median: 21.00) vs. 25.14 ± 4.68 (median: 16.00) months in metastatic tumours. CONCLUSIONS: RF ablation of lung lesions is a minimally invasive procedure that is useful in primary tumours (especially in stage I) and metastatic ones. RF has proven its usefulness in the multidisciplinary treatment of this pathology due to the low incidence of serious complications and survival obtained, considering that patients are elderly with significant comorbidity.

Anestesia en cirugía torácica: un reto en el siglo XXI / No disponible

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Linfomas primarios de pulmón / Primary pulmonary lymphoma

Los linfomas de tejido linfoide asociado a mucosas (MALT), aún siendo infrecuentes en la población, han sido considerados como una entidad propia que puede afectar a distintas topografías del organismo. Presentamos 3 casos de linfomas primarios pulmonares MALT diagnosticados entre 1995 y 2009. La determinación se realizó tras cirugía y estudio patológico. La forma de presentación fue como nódulo/masa, con diagnóstico definitivo tras la extirpación (AU)

Mucosa-associated lymphoid tissue (MALT) lymphomas, although rare in the population, are considered an entity per se, that may affect different topographies of the body. We present 3 cases of primary pulmonary MALT lymphomas diagnosed between 1995 and 2009. The diagnosis was made after surgery and pathology study. The presentation form was a nodule/mass, with definitive diagnosis after excision (AU)

Sternal resection and reconstruction after malignant tumours.

AIM: We present our experience of the resection of sternal tumours (both primary and metastatic), followed by reconstruction of soft-tissue and skeletal defects with a mesh and musculocutaneous flap. METHODS: Eleven patients were included in this study, all of which underwent sternal tumour resection and immediate chest wall repair. Reconstruction was accomplished with prosthetic material (polytetrafluoroethylene [PTFE]), a sandwich of polypropylene (Marlex-methylmethacrylate or titanium/polypropylene) and a pedicled musculocutaneous flap (pectoralis major, latissimus dorsi or rectus abdominis). Sternal tumours may arise from both primary (chondrosarcoma and neurofibrosarcoma) and secondary (local recurrence of breast carcinoma and metastatic disease from other organs) disease. RESULTS: Extubation did not result in paradoxical respiration in any of the patients in the study. The post-operative mortality rate was seen to be zero. One patient with a PTFE prosthesis had chest failure requiring immediate intubation and posterior prosthesis replacement. One mesh was removed two months after surgery. There was local recurrence in one patient and five patients died from distal metastases. The final patient is still alive with metastases at the time of presenting our results. CONCLUSIONS: Wide resection of sternal tumours provides good local control. Reconstruction with mesh and musculocutaneous flap is an effective technique for repairing such defects.

Sternal resection and reconstruction after malignant tumours

AIM: We present our experience of the resection of sternal tumours (both primary and metastatic), followed by reconstruction of soft-tissue and skeletal defects with a mesh and musculocutaneous flap. METHODS: Eleven patients were included in this study, all of which underwent sternal tumour resection and immediate chest wall repair. Reconstruction was accomplished with prosthetic material (polytetrafluoroethylene [PTFE]), a sandwich of polypropylene (Marlex-methylmethacrylate or titanium/polypropylene) and a pedicled musculocutaneous flap (pectoralis major, latissimus dorsi or rectus abdominis). Sternal tumours may arise from both primary (chondrosarcoma and neurofibrosarcoma) and secondary (local recurrence of breast carcinoma and metastatic disease from other organs) disease. RESULTS: Extubation did not result in paradoxical respiration in any of the patients in the study. The post-operative mortality rate was seen to be zero. One patient with a PTFE prosthesis had chest failure requiring immediate intubation and posterior prosthesis replacement. One mesh was removed two months after surgery. There was local recurrence in one patient and five patients died from distal metastases. The final patient is still alive with metastases at the time of presenting our results. CONCLUSIONS: Wide resection of sternal tumours provides good local control. Reconstruction with mesh and musculocutaneous flap is an effective technique for repairing such defects (AU)

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Expression of molecular markers in mediastinal nodes from resected stage I non-small-cell lung cancer (NSCLC): prognostic impact and potential role as markers of occult micrometastases.

BACKGROUND: Occult lymph node (LN) metastases are clinically relevant and confer a worse prognosis in non-small-cell lung cancer (NSCLC) patients. Current staging methods are unable to identify patients with poor outcome. Their detection requires both a more sensitive and specific technique. We aimed to assess the role of messenger RNA expression in pathologically negative LNs (pN0) of stage I NSCLC patients as markers of occult micrometastases and to correlate the results with local or distant tumor recurrence and survival. PATIENTS AND METHODS: Potential molecular markers were evaluated in 344 LNs and 38 tumors by quantitative real-time RT-PCR. Only CEACAM5 and PLUNC showed high expression in lung tumor tissue and null expression in RNA from benign LNs. RESULTS: Thirteen per cent of the LNs were positive for CEACAM5 and 16% for PLUNC. Eight of 38 NSCLC patients had positive expression in pN2 nodes by CEACAM5 and/or PLUNC and disease-free survival (P=0.028) and overall survival time was significantly worse in these patients compared with those with negative expression (P=0.0083). CONCLUSIONS: Quantitative real-time RT-PCR of CEACAM5 and PLUNC can estimate the presence of micrometastatic cells in LNs with greater precision than current staging method used for assessing tumor recurrence risk.

Endotracheal metastases from colon adenocarcinoma

Endotracheal metastases (ETM) from non-lung cancer are seldom seen. Their main clinical symptoms are cough, haemoptysis and dyspnoea, although occasionally an incidental finding is made during a bronchoscopy. Breast, colon and kidney adenocarcinoma might be associated with ETM, lung cancer being the most frequent cause. Its finding is associated with advanced disease but survival will depend on the primary origin, patient status and comorbidity. Therefore, treatment should be individual for each patient. In our centre we recommend pre-surgery bronchoscopy to exclude metastatic endotracheal lesions in patients with metastatic colon adenocarcinoma disease, as this might affect the final outcome and therefore management of the disease (AU)

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Protocol for the implantation of a venous access device (Port-A-Cath System). The complications and solutions found in 560 cases

INTRODUCTION: The cannulation of suitable peripheral veins may be a very painful experience. Implantable venous access systems have to some degree relieved this problem and help to provide an improvement in terms of quality of life. MATERIAL AND METHODS: We have evaluated 560 patients during a follow up period of two years. A low overall complication percentage of 7.32% was seen when using the venous access device. RESULTS: Complications and treatments were: pneumothorax; portal rotation or infection; catheter infection; embolism and migration; extravasation; partial or total obstruction of the device; rupture of the catheter or the membrane. CONCLUSIONS: There is no other system that allows repeated venous access on such a long term basis. Placing the devices completely under the skin allows the patient to conduct a normal life style, and its maintenance does not need any special care, with the exception of the monthly heparinised serum infusion. The preferred option is to insert the catheter through the cephalic vein in the delto pectoral groove (AU)

[Prognostic value of the carcinoembryonic antigen found in pleural lavage fluid from patients with lung carcinoma]. / Valor pronóstico del antígeno carcinoembrionario hallado en lavados pleurales de pacientes con carcinoma pulmonar.

OBJECTIVE: To detect the tumor marker carcinoembryonic antigen (CEA) in pleural lavage fluid taken during surgery from patients with pulmonary carcinoma without associated pleural effusion and assess its possible prognostic implications. PATIENTS AND METHODS: A prospective, observational study was undertaken to include consecutive patients who underwent surgical treatment for lung carcinoma in which pleural lavage was performed prior to closure of the thoracic cavity (study group). The same techniques and measurements were used in patients undergoing thoracotomy for benign disease (control group). The preoperative blood level of CEA was also quantified. RESULTS: In the study group, the median CEA levels in blood and pleural lavage fluid were 2.90 ng/mL and 0.40 ng/mL respectively; these figures are higher than those corresponding to the control group. A CEA level of 0.30 ng/mL in pleural lavage fluid was established as a cutoff point, based on the corresponding receiver operating characteristic curve, with a sensitivity of 68.4% and a specificity of 35.7%. A graph of survival in relation to this cutoff point revealed a statistically significant effect (P<.05). CONCLUSIONS: It is possible to detect CEA in pleural lavage fluid from the thoracic cavity of patients with lung carcinoma. The values obtained are higher than those found in fluid from patients without neoplastic disease, and this parameter functions as an independent predictor of disease course.

[Localized fibrous tumors of the pleura: clinical and surgical evaluation]. / Tumores fibrosos de localización pleural: valoración clinicoquirúrgica.

Solitary fibrous tumors of the pleura are uncommon and mainly arise in the pleura itself. Such tumors are generally asymptomatic and slow-growing. We report a series of 10 cases (8 men and 2 women with a mean age of 58.6 years) treated over a period of 54 months. The tumors were classified histologically as benign or malignant according to the criteria used by England. The treatment of choice was complete resection of the tumor. Six posterolateral thoracotomies and 4 video-assisted resections were performed. Histology showed a mixture of fibroblast-like cells and collagenous stroma. Sarcomatous degeneration was observed in the excised tumor of 1 patient. The patients were followed for a mean of 23.9 months. We conclude that although fibrous tumors of the pleura are considered benign histologically, complete resection and follow up for all patients are recommended.

[Intraparenchymal pulmonary inflammatory pseudotumors]. / Seudotumor inflamatorio pulmonar de localización intraparenquimatosa.

Inflammatory pseudotumors are rare entities which occasionally affect the pulmonary parenchyma. Their clinical diagnosis arises in a variety of ways and half the time they are detected by chance. Deciding on a therapeutic approach is difficult because a firm diagnosis is established only after studying the excised tissue. We describe our experience with the diagnosis, surgical treatment, and follow up of 4 cases of inflammatory pseudotumor located in the pulmonary parenchyma and treated by surgical resection (by thoracotomy or video assisted thoracoscopic surgery) with good outcomes following complete resection.

Seudotumor inflamatorio pulmonar de localizaciónintraparenquimatosa / Intraparenchymal Pulmonary Inflammatory Pseudotumors

Los tumores seudoinflamatorios son una rara entidad que en ocasiones afecta al parénquima pulmonar. Su diagnóstico clínico es variado, siendo un hallazgo casual en casi la mitad de los casos. Entraña una difícil decisión en cuanto a la mejor opción terapéutica, ya que el diagnóstico de certeza se establece tras el estudio de la pieza quirúrgica. Presentamos nuestra experiencia con el diagnóstico, tratamiento quirúrgico y seguimiento de 4 casos de tumores seudoinflamatorios de localización intraparenquimatosa tratados mediante resección quirúrgica (por toracotomía o cirugía videotoracoscópica) con buenos resultados tras la resección completa (AU)

[Video-assisted thoracoscopic surgery in the treatment of pneumothorax: 107 consecutive procedures]. / Cirugía videotoracoscópica en el tratamiento de los neumotórax: consideraciones sobre 107 procedimientos consecutivos.

The aim of this prospective study was to evaluate video-assisted thoracoscopic surgery (VATS) in primary and secondary spontaneous pneumothoraces. Over a 37-month period, 107 videothoracoscopic interventions were performed to treat spontaneous pneumothorax in 105 patients, 78 men and 27 women, whose average age was 28 years.Indications for surgery included recurrent ipsilateral pneumothorax (47 cases), persistent air leak (23 cases), hypertensive pneumothorax (14 cases), history of contralateral pneumothorax (13 cases), and elective surgery (10 cases). All of these patients were treated by endoscopic resection of the bullae (or apical zone in cases where the suspected abnormalities, or bullae, could not be visualized) plus physical pleurodesis. There were no perioperative deaths. Complications occurred in 6% of the cases of primary spontaneous pneumothorax and in 45% of the cases of secondary spontaneous pneumothorax. The complications among the secondary pneumothorax patients ranged widely from postoperative subcutaneous emphysema (resolved through simple, unassisted observation) to the need for an accessory minithoracotomy. Two patients (1.8%) suffered a recurrence of pneumothorax 4 and 8 months, respectively, after VATS treatment.

Cirugía videotoracoscópica en el tratamientode los neumotórax: consideraciones sobre107 procedimientos consecutivos / Video-assisted thoracoscopic surgery in the treatment of pneumothorax: 107 consecutive procedures

El objetivo del trabajo es valorar la cirugía videotoracoscópica en los neumotórax primarios y secundarios. Para ello se ha realizado un estudio prospectivo a lo largo de 37 meses, durante los cuales se practicaron 107 intervenciones videotoracoscópicas para el tratamiento de los neumotórax espontáneos en un total de 105 pacientes. Se incluyó a 78 varones y 27 mujeres con una edad media de 28 años. Las indicaciones quirúrgicas fueron: neumotórax recurrente ipsolateral en 47 casos; fuga aérea persistente en 23 casos; neumotórax hipertensivo en 14 ocasiones; cuadro de neumotórax contralateral antiguo en 13 casos, y cirugía electiva en 10 casos. Todos los pacientes fueron tratados con resección endoscópica de zona bullosa (o zona apical en caso de no visualizar la zona sospechosa) más pleurodesis física. No hubo mortalidad perioperatoria. Las complicaciones fueron del 6 por ciento en los casos de neumotórax espontáneos primarios y del 45 por ciento en los casos de neumotórax espontáneos secundarios, incluyendo éstas una amplia gama, desde el enfisema subcutáneo posquirúrgico resuelto con simple observación hasta la necesidad de minitoracotomía accesoria. Dos pacientes (1,8 por ciento) sufrieron recidiva del neumotórax a los 4 y 8 meses de la videocirugía, respectivamente (AU)

Thoracic venous aneurysms. Clinical observation.

Venous aneurysms are infrequent vascular alterations. Their origin is not well known, but pathologic study reveals probably a similar natural history than the arterial aneurysms. Their clinical significance arises from the complications they can originate, specially in certain locations, which include pulmonary embolism, and, on the other hand, differential diagnosis with certain malignant pathologies may be necessary, depending upon the clinical context. A patient is presented whose radiographic findings, in association with clinical factors, led to surgical exploration to rule out malignant lung tumor. A left subclavian vein aneurysm was finally diagnosed using magnetic resonance imaging.