Guiding Principles in the Management of Synchronous and Metachronous Primary Non-Small Cell Lung Cancer.

Multiple lung cancers can be found simultaneously, with incidence ranging from 1% to 8%. Documentation of more than 1 pulmonary lesion can be challenging, because these solid, ground-glass, or mixed-density tumors may represent multicentric malignant disease or intrapulmonary metastases. If mediastinal nodal and distant deposits are excluded, surgery should be contemplated. After surgical treatment of lung cancer, patients should be followed closely for an undetermined period of time. Good clinical judgment is of outmost importance in deciding which individuals will benefit from those surgical interventions and which are candidates for alternate therapies. Every case should be discussed in a multidisciplinary meeting.

Combined transection of the left common carotid artery and delayed left main bronchus disruption after blunt chest trauma.

A 26-year old female was hit in the cervical region by a large block of ice and admitted with stable vital signs and multiple fractures. Chest radiography demonstrated an enlarged mediastinum, and CT scan revealed a transection of the left common carotid artery at its origin, with a false aneurysm. The lesion was repaired using a median sternotomy, cardiopulmonary bypass, moderate hypothermia and cerebral antegrade perfusion through the right axillary artery. The bronchial lesion was diagnosed 2 days later and successfully treated with left posterolateral thoracotomy and the use of direct bronchial anastomosis.

Inflammatory pseudotumour of the lung.

Inflammatory pseudotumours of the lung are extremely rare. Their pathogenesis is controversial, their diagnosis is often difficult and their clinical behaviour may be unpredictable - ranging from benign to locally invasive, to metastatic in spite of an apparently 'benign' histology. A patient who presented with multiple recurrent lesions in the contralateral lung almost two years after the resection of a large primary tumour of the left upper lobe is reported.

History and current status of bronchoplastic surgery for lung cancer.

Sleeve lobectomy for carcinoma of the lung was first described as a compromised operation for patients whose pulmonary reserve was considered inadequate to permit pneumonectomy. Since then, many authors have suggested that bronchoplasties may provide as good if not better results than pneumonectomy in selected cases of primary carcinoma of the lung involving the proximal bronchial tree. In all reported series, lesions in the hilum of the right upper lobe are the commonest indication for sleeve lobectomy, although all lobes and segments of the lungs may on occasion be involved with tumors that are amenable to some form of lung-sparing bronchoplastic procedure. As a general statement, bronchoplasties should be considered in any case of lung cancer that can be completely resected by these techniques although some controversy persists about the application of these procedures in patients with N(1) or N(2) disease. Published reports document a 30-day operative mortality of 0%-5%. Complications peculiar to sleeve lobectomy are an increased incidence of retained secretions, bronchovascular fistulas, and a potential for an increased incidence of local recurrence. Most major reports document a 5-year survival of 40%-50% and functional results that are significantly better than those obtained following pneumonectomy.

Sleeve pneumonectomy.

Lung cancer involving the carina can be treated by surgery, but patients must be carefully selected before the operation. Because pneumonectomy is required in addition to carinal resection, patients must be able to withstand the procedure, and they must be told that the operative mortality is 2 to 4 times higher than what is expected after standard pneumonectomy. Patients who have mediastinal nodal disease documented preoperatively by mediastinoscopy should not have this operation. In general, it is possible to perform a safe operation if the surgeon adheres to the principles of healthy bronchial suturing and restricts airway resection to a maximum distance of 4 cm. Surgeons must always remember, however, that it is better and safer to accept a positive resection margin than to have to deal with a bronchopleural fistula caused by anastomotic separation. Finally, reported long-term survival rates of 25% to 40% justify the use of this procedure.

Sleeve lobectomy versus pneumonectomy for lung cancer: a comparative analysis of survival and sites or recurrences.

BACKGROUND: Sleeve lobectomy (SL) in a lung-saving procedure indicated for central tumors for which the alternative is pneumonectomy (PN). Although it has been suggested that it may provide as good if not better survival results than pneumonectomy in the treatment of lung cancer, there are very few reports of clinical series comparing operative mortality, survival, and sites of recurrences between these procedures. METHODS: Survival and sites of recurrences were analyzed and compared in 1,230 consecutive patients who underwent PN (n = 1,046) or SL (n = 184) in a single institution. Sleeve lobectomy was always done when technically possible. Thus PN was reserved for lesions that could not be removed by a bronchoplastic procedure. Pathologic staging was accomplished by nodal sampling except for N2 and selected N1 patients who underwent mediastinal lymphadenectomy. Ultimately, all patients were staged according to the 1997 TNM nomenclature. RESULTS: There were 3 operative deaths of the 184 SL patients (operative mortality of 1.6%) and 55 operative deaths of the 1,046 PN patients (operative mortality of 5.3%, p = 0.036). Follow-up was complete for all 1,230 patients. For the entire group, survival at 5 years was 52% after SL and 31% after PN (p < 0.0001). These rates for patients with complete resection were 58% for SL and 33% for PN (p = 0.021). There was also a significant difference in survival favoring SL for patients with pathologic stage I (p = 0.018) and stage II (p = 0.005) disease. When recurrences occurred (n = 577), the site of first recurrence was local in 22% of patients with SL and in 35% of patients with PN. CONCLUSIONS: Sleeve lobectomy can be done with a much lower risk of operative mortality than PN. Although it is recognized that stage for stage, PN patients likely have more advanced disease, long-term survival and local control are significantly better when complete resection can be achieved by SL.

Role of Eloesser flap and thoracoplasty in the third millennium.

In the modern era of thoracic surgery, few indications remain for thoracoplasty. Indeed, many surgeons believe that the resulting deformity outweighs the usefulness of collapse therapy. Rather than trying to obliterate chronic spaces, these surgeons advocate myoplasty techniques to fill the space. Unfortunately, these techniques are not minor procedures and two to three operations are often necessary to solve the problem. This is the reason why thoracoplasty remains the best option in selected patients. In some cases, it should be a first-line procedure rather than as a last resort when everything else has failed. In their discussion of the article by Horrigan and Snow [31], Pairolero and Trastek [44] summarized well the current attitudes toward these different concepts: "Although management of the chronically infected pleural space has changed over the years, the goals of therapy remain the same to conserve the patient's life with a healed chest wall without evidence of infection. Determination of which techniques are necessary to achieve these goals must be tailored to the individual patients."