[Videothoracoscopy in the diagnosis and treatment of hemothorax]. / La videotoracoscopia nella diagnosi e nel trattamento degli emotoraci.

Video assisted thoracic surgery (VATS) has assumed greater importance in the management of pleural diseases. From 1994 to 1998 the Authors report their experience about 11 cases of hemothoraces depending on various causes: 6 hemothoraces and 3 hemopneumothoraces, some spontaneous or iatrogenic, others in patients with chest trauma; 2 clotted hemothoraces. All patients were studied by VAT detecting the source of bleeding in 6 cases of acute hemothorax and in 3 cases of acute hemopneumothorax; in 5 cases the lesions were successfully repaired with thoracoscopic technique. In others 4 patients the VATS approach was converted to thoracotomy for the seriousness of lesions: 3 acute hemothoraces (1 patient with penetrating thoracic firearms injury, 1 patient with extended lung laceration, 1 patient with iatrogenic lesion of right subclavian artery); 1 acute hemopneumothorax in one patient with penetrating thoracic firearms injury and left hemidiaphragmatic double perforation: in this case laparotomy was also operated in order to exclude others abdominal lesions. 2 cases of clotted hemothorax were operated by VATS performing the removal of clots after their fragmentation by endobabcock and pleural irrigation-aspiration with physiological solution. No procedure related complications were occurred. The authors conclude that the video-thoracoscopic approach is certainly advantageous for the management of spontaneous, traumatic or iatrogenic acute hemothoraces. This technique permits, with minimal traumatism and very little complications, the correct therapeutic programming (VATS operation or conversion to thoracotomy). However some hemothoraces (hemothoraces in patients with serious cranial trauma, with spleen rupture, with great vessels rupture, with heart rupture or with massive post-operating hemothorax) contro-indicate the thoracoscopic treatment: immediate thoracotomy and/or laparotomy, in these cases, is indispensable. In the treatment of clotted hemothoraces the VATS is a favourable alternative to thoracotomy, reforming the pleural cavity with minimal traumatism and avoiding tardive complications.

Clinical diagnostic application of 111In-DTPA-octreotide scintigraphy in small cell lung cancer.

Some years ago it was proved that a good percentage of small cell lung cancers, classified among cancers of the APUD system, produces somatostatin receptors that can be detected in vivo by scintigraphy with 111In-DTPA-octreotide. With the method in the whole body it is possible to identify the principal neoformation and the probable metastases. The authors present a study of 21 patients afflicted with small cell lung cancer diagnosed histologically. The study, carried out between January 1995 and December 1997, compared the radiologic iconography of the CT scan with the scintigraphic map obtained by a planar scintigraphy and in SPECT 1, 4 and 24-hr after iv injection of 110 MBq of 111In-DTPA-octreotide. The comparison was made with reference to the principal neoplasm and probable metastases. A scintigraphic study, a CT of restaging and a follow-up, done after 3 and 6 months of chemotherapy, on 15 patients with cancer that produces somatostatin receptors proved that the neoplasm sometimes regresses and sometimes progresses. In the latter case, it is possible to identify cerebral, mediastinal and hepatic metastases with the administration of 200 microg of octreotide 3 times a day for 7 days before the scintigraphy. In fact, the administration lowers background activity. The authors concluded that scintigraphy with 111In-DTPA-octreotide plays an important part in the study of patients afflicted with small cell lung cancer. Scintigraphy identifies the subgroups of patients who can be cured with somatostatin analogues together with chemotherapy. Scintigraphy presents a good sensibility in the re-staging and in the follow-up of patients who are treated, even though it is difficult to identify subdiaphragmatic metastases where liver, spleen and kidney show an increase in 111In-DTPA-octreotide.

Carboplatin, ifosfamide, and vinorelbine in the treatment of advanced non-small-cell lung cancer: a phase II study.

The authors evaluated the efficacy and toxicity of the combination of carboplatin, ifosfamide, and vinorelbine in the treatment of advanced non-small-cell lung cancer. From March 1994 through March 1996, 56 previously untreated patients with stage IIIB or stage IV non-small-cell lung cancer with measurable lesions and good performance status were entered in the study. The chemotherapy schedule was as follows: carboplatin 100 mg/m2 and ifosfamide 1,500 mg/m2 with mesna on days 1, 2, and 3; vinorelbine 25 mg/m2 on days 1 and 8, every 21 days; for a total of six courses. Among 55 evaluable patients there were three complete responses (5%) and 22 partial responses (40%), for a response rate of 45% (95% confidence interval, 32-59%). The median response duration was 10.3 months (range, 2.5-27.7 months), and median survival time was 11.3 months (range, 1.1-28.1 months). The survival rate at 1 year was 48%. Toxicity included hematologic toxicity in 60% of the 247 treatment cycles administered, nausea, alopecia, and neuropathy. One pathologic complete response was observed in a patient with stage IIIB disease who became operable after four courses of chemotherapy. The outpatient treatment with carboplatin, ifosfamide, and vinorelbine shows activity in advanced non-small-cell lung cancer. The toxicity was well tolerated by patients with a good performance status.

[Chondro-costal abnormalities of anterior wall of the chest: operative indications and surgical technique]. / Le malformazioni condro-costali della parete anteriore del torace: indicazioni operatorie e tecnica chirurgica.

The aim of this study is to evaluate the utility of surgical treatment in patients with pectus excavatum (PE) or pectus carinatum (PC). Fifteen patients underwent surgical treatment because of their psycological and anatomical condition, more serious in 6 patients (5 with PE and 1 with PC). The degree of these chest wall deformities was evaluated as resulting from CT scan of the thorax, by the ratio between the transversal and the front/back diameters, according to Haller. The Authors recommend surgical operation in the post-puberal age up to 21 years because of good results obtained using Ravitch approach (only 1 case of partial relapse of PE), even though modified in PE cases with the application of flat steel prosthesis and in PC cases for uncutting the perichondral beds. The choice of surgical procedure derives, in our opinion, from the correction of these anatomic deformities and from the greater sense of improved cosmesis that might result.

Diagnostic and therapeutic approaches for masses in the posterior mediastinum.

Between January 1980 and December 1997 twenty-one patients with a mass in the posterior mediastinum came under our observation. All of the patients underwent chest radiography, bronchoscopy, respiratory function tests, perfusional and ventilatory radionuclide scans, a computed tomography (CT) of the chest and blood gas analysis. In cases involving neurogenic tumours magnetic resonance imaging (MRI) was used. Ten patients underwent CT guided transthoracic needle biopsy. The excision was performed by means of a thoracotomy in 12 cases (57.1%) and by video assisted thoracoscopy surgery (VATS) in the other 9 (42.9%); no deaths were recorded. Eleven neurilemmomas, two bronchogenic cysts, two paragangliomas, two neuroepitheliomas, one neurogenic sarcoma and three esophageal duplications were found. The authors believe an accurate pre-operative assessment of the lesion can be obtained using CT and MRI. The video assisted thoracoscopy (VAT) is a useful method of diagnosis and treatment as it can be converted into VATS if the lesion is benign or cystic. Thoracotomy is necessary when the mass is malignant or when there is adhesion to or invasion of surrounding tissues.

[Combined surgical treatment of pulmonary neoplasms with single brain metastasis]. / Trattamento chirurgico combinato delle neoplasie polmonari con metastasi cerebrale unica.

The combined surgical treatment of primitive lung cancer with single brain metastasis is a frequently debated but still controversial problem. Up to day several therapeutic approaches are generally integrated (surgery, radiotherapy, chemotherapy) according to the clinical patterns and the technical possibilities. In general, the combined surgical operation (thoracotomy + craniotomy) when it is possible to be done, followed or proceeded by chemo-radiotherapy, has allowed to achieve a prolonged survival in these patients, maintaining an acceptable quality of life. The authors analyze 10 cases treated by thoracotomy and craniotomy at the Chair of Thoracic Surgery of University of L'Aquila. Although consisting of a small number of cases, this experience allows to detect the particular problems concerning these patients. The indications to the combined surgical treatment are considered, evaluating the surgical operation which is to be performed as first on the basis of lung cancer staging and of the location and size of the brain metastases. Finally the patients survival and their quality of life are considered.

[Use of magnetic resonance in the study of mediastinal diseases]. / Impiego della RM nello studio della patologia mediastinica.

Clinical research on 75 cases of mediastinal masses has been carried out with the aim of evaluating the diagnostic value of Magnetic Resonance (MR). Results which have been achieved point to a remarkable potentiality of MR especially in the characterization and spatial definition of the masses and in the study of the spinal canal. These results, as well as the non-invasivity of the procedure, lead us to consider MR as an investigation of primary importance in the diagnostic assessment of mediastinal pathology.

[Diaphragmatic hernias due to "strain": apropos a case report]. / Le ernie diaframmatiche "da sforzo": a proposito di un caso osservato.

After a brief report on the pathophysiology of diaphragmatic hernias, the authors describe a case of strain diaphragmatic hernia. Considering the rarity and the difficulty to make an immediate diagnosis of this pathology, the authors stress diagnostic problems of strain chest pain and surgical treatment of strain diaphragmatic hernias.

[Importance of bronchial biopsy in the histologic typing of cancer of the lung. Case study contribution (1980-1987)]. / Il significato della biopsia bronchiale nella tipizzazione istologica del cancro polmonare. Contributo casistico (1980-1987).

The diagnostic significance of the histological typing of lung cancer carried out on preoperative bronchoscopic biopsy samples is assessed in relation to final morphological diagnosis on operating material. In this connection 176 of 624 cases of lung cancer documented histologically from January 1980 to December 1987 in which preoperative biopsy sample was followed by removal of the lung are analysed. The 4 basic histotypes of lung cancer according to the WHO (1981) classification are considered. A positive diagnosis for cancer was encountered in 138 cases (78.4%) with histotype confirmed in 122, whereas a negative diagnosis was encountered in 38 cases (21.6%). These findings also permitted further considerations, including the possible limitations of the technique.

[Evaluation of carcinoembryonic antigen (CEA) in the follow-up of patients with inoperable lung cancer undergoing polychemotherapy]. / Valutazione dell'antigene carcino-embrionario (CEA) nel follow-up di pazienti con carcinoma polmonare inoperabile in corso di polichemioterapia.

Twenty-two patients with surgically incurable lung cancer undergoing systemic chemotherapy have been studied with serial determinations of CEA levels during their therapy. The changes of CEA levels in each patients showed that the assay may be useful to evaluate the effects of therapy. The purpose of this preliminary study is to explore the possibility that CEA assay may be a useful guide to the subsequent clinical response of the patient to the drug.