Angiosarcoma pulmonar / Lung angiosarcoma

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[Thoracocentesis for the assessment of lung cancer with pleural effusion]. / La toracocentesis en la evaluación del cáncer de pulmón con derrame pleural

OBJECTIVE: To analyze the pleural and mediastinal effect of thoracentesis tumor-positive cytology in pleural effusions (PE) detected by chest X ray of lung cancer patients. PATIENTS AND METHODS: The study was performed in patients with lung cancer for whom PE was evident in chest X ray films, who then underwent thoracentesis followed by video-assisted thoracoscopy (VAT) to evaluate direct pleural tumor infiltration, mediastinal node involvement and the existence of pleural metastasis. Patients without contraindication underwent the procedure, even if tumor positive cytology was present. When pleural metastasis was found the treatment employed was talc pleurodesis and chemotherapy. Descriptive statistics were compiled and the validity of VAT for pleural metastasis diagnosis, of thoracentesis pleural cytology to detect infiltration of the tumor-adyacent pleura, N2 disease and pleural metastasis were calculated. Survival was also analyzed. RESULTS: PE was present in 188 of 971 consecutive lung cancer patients. Seventy two PEs were visible in the chest X ray films. Volume exceeded 425 mL. Tumor positive pleural cytology was detected in 29 cases (40%). Pleural metastasis were found in 54 patients, 23 of whom had tumor positive pleural cytology. In the other 6 patients with positive cytology the primary neoplasm infiltrated the visceral pleura, completely in 5. In 4 of those 5, the mediastinal pleura was also involved. The primary tumor and diseased lymph nodes were removed from 11 patients, 3 of them with tumoral pleural cytology. Visual pleural inspection by VAT had a sensitivity of 93%, specificity of 82%, positive predicted value (PPV) of 94% and negative predicted value (NPV) of 78% for the diagnosis of pleural metastasis. Thoracentesis cytology showed a sensitivity of 43%, specificity of 67%, PPV of 79% and NPV of 28% for pleural metastasis. For the evaluation of adjacent pleura infiltration, without pleural metastasis, the sensitivity of cytology was 40%, specificity 100%, PPV 100% and NPV 25%. For mediastinal node invasion clinically evaluated, the sensitivity of cytology was 55%, specificity of 62%, PPV 18% and NPV 90%. Survival after thoracotomy was 39% after 2 years, and the median survival time was 14.5 months. In the 11 resected patients, survival was 53% at two years. The difference in survival between patients treated by thoracotomy and those treated by talc pleurodesis after VAT was significant (p < 0.01). The 3 resected patients with pleural tumor-positive cytology survived 84, 39 and 25 months. CONCLUSIONS: Nineteen percent of patients with lung cancer have PE, of which 7% can be seen in chest X ray films. In such patients the likelihood of pleural metastasis is 75%. Pleural metastasis is not necessarily present when PE cytology indicates that tumor is present. VAT can be considered the ideal technique for the assessment of direct pleural invasion by the tumor or of pleural metastasis.

La toracocentesis en la evaluación del cáncer de pulmón con derrame pleural / Thoracentesis for the assessment of lung cancer with pleural effusion

OBJETIVO: Analizar la repercusión pleural y ganglionar mediastínica de la citología tumoral obtenida por toracocentesis del derrame pleural (DP) diagnosticado mediante radiografía de tórax en pacientes con cáncer de pulmón (CP). PACIENTES Y MÉTODOS: Estudio realizado en pacientes con CP primario y DP evidente en la radiografía de tórax a los que se les realizó toracocentesis seguida de videotoracoscopia (VT) para valorar la infiltración pleural directa por el tumor, la afección ganglionar mediastínica y la existencia de diseminación metastásica pleural. Fueron intervenidos quirúrgicamente aquellos sin contraindicación, pese a tener citología tumoral. Al encontrar metástasis pleural se practicó pleurodesis con talco y tratamiento quimioterápico. El estudio estadístico contempló los siguientes aspectos: descripción de las variables epidemiológicas; validez de la VT para el diagnóstico de metástasis pleural y de la citología por toracocentesis para evaluar la infiltración pleural por contigüidad, enfermedad N2 y la existencia de metástasis pleural; supervivencia. RESULTADOS: En 971 pacientes consecutivos con CP hubo 188 con DP, 72 visibles en la radiografía de tórax. El volumen fue superior a 425 ml. La citología fue tumoral en 29 casos (40 per cent). Hubo metástasis pleural en 54 pacientes (75 per cent), 23 con citología tumoral. En los otros 6 pacientes con citología tumoral, la neoplasia primaria infiltraba la pleura visceral, en 5 de forma completa, 4 de los cuales presentaban infiltración de la pleura mediastínica. Se realizó la exéresis del tumor primario y adenopatías en 11 pacientes, 3 con citología tumoral. La evaluación pleural de visu por VT para el diagnóstico de mestástasis pleural dio una sensibilidad (S) del 93 per cent, especificidad (E) del 82 per cent, un valor predictivo positivo (VPP) del 94 per cent y un valor predictivo negativo (VPN) del 78 per cent. La citología por toracocentesis para el diagnóstico de metástasis pleural presentó: S 43 per cent, E 67 per cent, VPP 79 per cent y VPN 28 per cent; para infiltración pleural por contigüidad, sin metástasis pleural: S 40 per cent, E 100 per cent, VPP 100 per cent y VPN 25 per cent; y en la invasión ganglionar mediastínica evaluada clínicamente: S 55 per cent, E 62 per cent, VPP 18 per cent y VPN 90 per cent. La supervivencia tras toracotomía alcanzó el 39 per cent a los 2 años, con una mediana de 14,5 meses y en los 11 pacientes resecados fue del 53 per cent a los 2 años. La comparación de las supervivencias de los pacientes intervenidos por toracotomía y los tratados mediante pleurodesis tras VT fue significativa (p < 0,01). La supervivencia de los 3 pacientes con citología tumoral resecados alcanzó 84, 39 y 25 meses. CONCLUSIONES: El 19 per cent de los pacientes con CP tiene un DP y el 7 per cent puede ser diagnosticado en la radiografía de tórax, en cuyo caso la probabilidad de que coexista con metástasis pleural es del 75 per cent. El hallazgo de citología tumoral en el DP no es equivalente de metástasis pleural. La toracoscopia se puede considerar la técnica idónea en el análisis de la invasión pleural directa por el tumor o la diseminación metastásica. (AU)

[Surgery and combined therapy for non-small cell lung cancer with invasion of the mediastinal nodes. A retrospective study]. / Resultados del tratamiento quirúrgico y terapia combinada en el cáncer de pulmón no microcítico con invasión ganglionar mediastínica. Estudio retrospectivo.

OBJECTIVE: To analyze the survival of patients classified N2M0 (N2 cytology/histology)with non-small cell lung cancer treated by surgical resection of the primary tumor, lymphadenectomy and neo-adjuvant therapy. PATIENTS AND METHODS: Among 1,043 consecutive patients with lung cancer treated between 1990 and 2000, 155 were classified N2M0 by histology. Of 130 patients undergoing thoracotomy, excision of the primary pulmonary tumor and lymphadenectomy were performed in 116. Among the 116 N2M0patients undergoing surgical resection, 23 were diagnosed N2c(c3)by mediastinoscopy and/or mediastinotomy and received induction chemotherapy (CT) with mitomycin/ifosfamide/cisplatin (3 cycles)and 93 were diagnosed N2pM0 after examination of samples of mediastinal lymph tissue taken during thoracotomy; for 19 of these patients,earlier surgical exploration of the mediastinum had been negative. The patient diagnosed N2p after thoracotomy also received CT and/or radiotherapy (RT). N2p patients who received induction CT also received RT. Those who were negative after lymphadenectomy and severely ill patients received no adjuvant therapy of any type. RESULTS: Mean survival of resected patients (23/49) diagnosed N2(C3) by mediastinoscopy/mediastinotomy and who received induction CT was 18 months. Survival at 1, 2 and 5 years was 80%, 45% and 30%, respectively. No postoperative deaths occurred in this group. One patient developed a bronchopleural fistula. Nine patients showed no signs of residual mediastinal node disease after lymphadenectomy. The mean survival of resected patients (93/106) diagnosed N2p after thoracotomy was 13 months and survival rates at 1, 2 and 5 years were 56%, 31% and 19%,respectively. Fourteen patients in this group died within 30 days of surgery. Nine patient developed bronchopleural fistulas. The difference in survival between the two groups was not significant. CONCLUSIONS: Histologic or cytologic confirmation of N2 disease can be considered to indicate poor prognosis. Standard, complete surgery with induction CT in selected patients improves survival for those diagnosed N2 upon thoracotomy, with no statistically significant differences.

[Surgical treatment of non-small cell lung cancer with mediastinal node invasion. A retrospective study]. / Resultados del tratamiento quirúrgico y terapia neoadyuvante en el cáncer de pulmón no microcítico con invasión ganglionar mediastínica. Estudio retrospectivo.

OBJECTIVE: To analyze the survival of patients classified as N2M0 (N2 by cytohistology) with non-small cell lung cancer treated by surgical resection of the primary tumor and lymphadenectomy. PATIENTS AND METHODS: Among 1043 consecutive patients with lung cancer who were considered for surgery between 1990 and 2000, 155 were classified N2M0 by histology. Surgical exeresis of the primarily pulmonary tumor and lymphadenectomy were performed in 116 patients of the 130 patients who underwent thoracotomy. Among the 116 N2M0 patients undergoing surgical resection, 23 were diagnosed N2c(C3) by mediastinoscopy and/or mediastinotomy and were given induction chemotherapy (ChT) (mitomycin/ifosfami-de/cisplatin, 3 cycles) and 93 were diagnosed N2pM0 based on samples obtained from mediastinal lymph tissue during thoracotomy. Nineteen of the latter had previously been classified negative during surgical exploration. The patients diagnosed N2p after thoracotomy were given adjuvant ChT, radiotherapy or both. N2p patients who received induction therapy were given radiotherapy. Those found negative after lymphadenectomy and patients with severe disease were given no adjuvant treatment. RESULTS: Mean survival was 18 months for resected patients diagnosed N2 by mediastinoscopy/mediastinotomy and with induction ChT and survival at one, two and five years was 80%, 45% and 30%, respectively. No postoperative mortality was recorded in this group. One patient suffered bronchopleural fistula. Nine patients showed no residual mediastinal node disease after lymphadenectomy. The mean survival of resected patients diagnosed N2p by thoracotomy was 13 months, and one, two and five year survival rates were 56%, 31% and 19%, respectively. Fourteen patients died within 30 days of surgery. Nine patients developed a bronchopleural fistula. The difference in survival of the two groups was not significant. CONCLUSIONS: The prognosis after cytohistologic confirmation of N2 disease can be considered poor. Standard, complete surgery plus induction therapy in screened patients improved survival for those diagnosed N2 by thoracotomy, with no statistically significant differences.

Resultados del tratamiento quirúrgico y terapia combinada en el cáncer de pulmón no microcítico con invasión ganglionar mediastínica. Estudio retrospectivo / Surgery and combined therapy for non-small cell lung cancer with invasion of the mediastinal nodes. A retrospective study

OBJETIVO: Analizar la supervivencia de los pacientes clasificados N2M0 (N2 citohistológicos) con cáncer de pulmón no microcítico tratados mediante resección quirúrgica del tumor primario, linfadenectomía y terapias neo y adyuvantes asociadas. PACIENTES Y MÉTODOS: Entre 1.043 pacientes consecutivos con cáncer de pulmón valorados para cirugía desde 1990 hasta 2000, hallamos 155 clasificados N2M0 por histología y realizamos la exéresis quirúrgica del tumor pulmonar primario y la linfadenectomía en 116 pacientes de los 130 que llevaron toracotomía. En los 116 pacientes N2M0 con resección quirúrgica, 23 fueron diagnosticados N2c(C3) por mediastinoscopia y/o mediastinotomía y siguieron quimioterapia (QT) de inducción (mitomicina/ifosfamida/cisplatino, 3 ciclos), y otros 93 se diagnosticaron N2pM0 con las muestras obtenidas del tejido linfático mediastínico en la toracotomía; de estos últimos, 19 tenían una exploración quirúrgica mediastínica previa negativa. Los pacientes diagnosticados N2p tras la toracotomía siguieron tratamiento adyuvante con QT, radioterapia (RT), o ambas. A los N2p que siguieron terapia de inducción se les administró RT. Los negativizados tras la linfadenectomía y los pacientes graves no recibieron tratamiento adyuvante alguno. RESULTADOS: La mediana de supervivencia de los pacientes resecados (23/49) diagnosticados N2(C3) por mediastinoscopia/mediastinotomía y con QT de inducción fue de 18 meses, y la supervivencia al año, a los 2 y a los 5 años fue del 80, el 45 y el 30 por ciento, respectivamente. No hubo mortalidad postoperatoria en este grupo. Un paciente presentó una fístula boncopleural. En 9 pacientes no se evidenció enfermedad ganglionar mediastínica residual tras la linfadenectomía. La mediana de supervivencia de los pacientes resecados (93/106) diagnosticados N2p en la toracotomía fue de 13 meses, y al año, 2 y 5 años presentaron una supervivencia del 56, el 31 y el 19 por ciento, respectivamente. Fallecieron 14 personas en los 30 primeros días del postoperatorio. Nueve pacientes presentaron una fístula broncopleural. La diferencia de supervivencia entre los pacientes de ambos grupos no fue significativa. CONCLUSIONES: La confirmación citohistológica de enfermedad N2 puede considerarse de mal pronóstico. La cirugía estándar y completa, con terapia de inducción en los pacientes seleccionados, mejoró la supervivencia que presentaron aquellos diagnosticados N2 en la toracotomía, sin diferencias estadísticas significativas (AU)

Resultados del tratamiento quirúrgico y terapia neoadyuvante en el cáncer de pulmón no microcítico con invasión ganglionar mediastínica. Estudio retrospectivo / Surgical treatment of non-small cell lung cancer with mediastinal node invasion. A retrospective study

OBJETIVO: Analizar la supervivencia de los pacientes clasificados N2M0 (N2 citohistológico) con cáncer de pulmón no microcítico tratados mediante resección quirúrgica del tumor primario y linfadenectomía. PACIENTES Y MÉTODO: Entre 1.043 pacientes consecutivos con cáncer de pulmón valorados para cirugía desde 1990 al 2000, hallamos 155 clasificados N2M0 por histología y realizamos la exéresis quirúrgica del tumor pulmonar primario y la linfadenectomía en 116 pacientes de los 130 a quienes se había practicado toracotomía. En los 116 pacientes N2M0 con resección quirúrgica, 23 fueron diagnosticados N2c(C3) por mediastinoscopia y/o mediastinotomía y siguieron quimioterapia (QT) de inducción (mitomicina/ifosfamida/cisplatino, 3 ciclos) y otros 93 fueron diagnosticados como N2pM0 con las muestras obtenidas del tejido linfático mediastínico en la toracotomía, 19 de éstos con exploración quirúrgica mediastínica previa negativa. Los pacientes diagnosticados N2p tras la toracotomía recibieron tratamiento adyuvante con QT, radioterapia (RT) o ambas. A los N2p que recibieron terapia de inducción se les administró RT. Los negativizados tras la linfadenectomía y los pacientes graves no recibieron tratamiento adyuvante alguno. RESULTADOS: La mediana de supervivencia de los pacientes resecados diagnosticados N2 por mediastinoscopia/mediastinotomía y con QT de inducción fue de 18 meses, y la supervivencia al año, a los 2 y a los 5 años fue del 80, el 45 y el 30 por ciento, respectivamente. No hubo mortalidad postoperatoria en este grupo. Un paciente presentó una fístula broncopleural. Nueve pacientes no manifestaron enfermedad ganglionar mediastínica residual tras la linfadenectomía. La mediana de supervivencia de los pacientes resecados diagnosticados N2p en la toracotomía fue de 13 meses, y al año, a los 2 y a los 5 años presentaron una supervivencia del 56, el 31 y el 19 por ciento, respectivamente. Fallecieron 14 pacientes en los primeros 30 días del postoperatorio. Nueve pacientes presentaron una fístula broncopleural. La diferencia de supervivencia entre los pacientes de ambos grupos no fue significativa. CONCLUSIONES: La confirmación citohistológica de enfermedad N2 puede considerarse de mal pronóstico. La cirugía estándar completa, con terapia de inducción en pacientes seleccionados, mejoró la supervivencia que presentaron aquellos diagnosticados N2 en la toracotomía, sin diferencias estadísticamente significativas (AU)

Osteoartropatía hipertrófica asociada a adenocarcinoma pulmonar: importante mejoría clínica postquirúrgica / Hypertrophic osteoarthropathy associated with pulmonary adenocarcinoma: important improvement after tumor resection

Propósito: La Osteoartropatía Hipertrófica es una entidad asociada generalmente a procesos neoplásicos intratorácicos. Material y métodos: Se presenta un caso de Osteoartropatía Hipertrófica asociada a un adenocarcinoma de pulmón. Resultado: Remisión del síndrome tras la resección del carcinoma de pulmón primitivo. Conclusiones: Ante la presencia del síndrome clínico debería descartarse la posibilidad de neoplasia oculta, fundamentalmente intratorácica (AU)

Divertículo pericárdico paratraqueal / Paratracheal pericardial diverticulitis

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[Atypical carcinoid tumor of the thymus]. / Tumor carcinoide atípico del timo.

We report a male patient with atypical carcinoid tumor diagnosed by anterior mediastinotomy and biopsy after a mass was observed by chance on a chest film. The presence of neuroendocrine markers, notably chromogranin, cytokeratin, synapto-physin and neuro-specific enolase, facilitated diagnosis. Because the tumor was infiltrative, full surgical excision and radiotherapy to the mediastinum (50 Gy) were provided. We describe the incidence, clinical presentation, diagnosis, treatment and prognosis of these tumors.

[Solitary adrenal metastasis of pulmonary cancer]. / Metástasis única suprarrenal por cáncer de pulmón.

We describe the case of a 46-year-old man with lung cancer and simultaneous solitary adrenal metastases. Adrenalectomy was performed 12 weeks after lung resection through a right subcostal laparotomy. Treatment was complemented with chemotherapy. Twelve months after adrenalectomy the patient was found free of signs of disease and was in satisfactory condition. The advantages of and indications for surgical resection of suprarenal metastasis are discussed in the light of published literature. In some cases, survival may improve with exeresis and chemotherapy.

[Approach to bronchopleural fistula in patients undergoing lung cancer surgery. A prospective study]. / Abordaje de la fístula broncopleural en pacientes intervenidos de cáncer de pulmón. Estudio prospectivo.

Twenty-four cases of bronchopleural fistula were found by fiberoptic bronchoscopy performed in 526 consecutive patients undergoing surgery for diagnosis or treatment of lung cancer between February 1990 and January 1997 in Hospital General Universitario in Valencia (Spain). In 327 of the patients lung resection was performed. Clinical symptoms included fever, purulent or bloodstained expectoration, chest pain, dyspnea and general unfitness, with 83.33% of the patients having pleural empyema. Treatment was based on pleural drainage and broad-spectrum antibiotic therapy, along with planning of the appropriate surgery technique to each patient. Surgery consisted in re-thoracotomy and bronchial closure in early detection cases without evidence of infection (< 48 h); thoracostomy (Clagett) and second stage myoplasty if confirmed pleural infection; thoracoplasty in cases of incomplete fistulas that were unresolved by pleural drainage. Biological glues were delivered by fiberoptic bronchoscope in one patient. The incidence of bronchopleural fistula was studied, as were associated factors and the results obtained by various surgical techniques.

[Prognostic value of positive cytology found in pleural lavage of patients with cancer of the lung. Prospective study]. / Valor pronóstico de la citología positiva hallada en el lavado pleural de pacientes con cáncer de pulmón. Estudio prospectivo.

Pulmonary neoplasms can deposit malignant cells in the pleural cavity by a variety of mechanisms, depending not only on histological type but also on clinical stage. We investigated the effect on survival rate of a finding of malignant cells in pleural lavage. We also investigated the effect of the presence of pleural metastasis on postoperative course of disease. Two hundred surgical patients at Hospital General Universitario in Valencia between 1 February 1990 and 30 March 1993 were studied. Two groups were formed. Group one: 150 patients with lung cancer, none of whom had had pleural effusion prior to suffering transthoracic puncture during the preoperative study. Patients treated with parallel chemotherapy or radiotherapy were excluded in order to circumvent false positives. Group two: 50 patients with no tumors who underwent thoracotomy for reasons other than lung cancer. All patients underwent pleural lavage with saline before and after lung exeresis. We found 26.6% (40/150) positive cytologies in the pre-and postoperative lavages in the first group. None were found in the control group.

[A patient with Rendu-Osler-Weber disease and pulmonary arteriovenous malformations treated satisfactorily by embolization]. / Paciente con enfermedad de Rendu-Osler-Weber y malformaciones arteriovenosas pulmonarares tratadas satisfactoriamente mediante embolización.

A 41-years-old woman with multiple arteriovenous lung malformations in a context of Rendu-Osler-Weber disease is described. The patient had a history of cutaneous and mucosal telangiectasia, frequent epistaxis and one episode of central artery embolism in the right retina. Malformations in the vascular territories of both lungs (right lower lobe and lingula) were detected by X-rays and magnetic resonance. Progressive dyspnea along with serious antecedents indicated that aggressive treatment was required. The malformations were embolized in the vascular radiology treatment center.

[Congenital tracheoesophageal fistula in a 15-year-old male]. / Fístula traqueoesofágica congénita en un varón de 15 años.

We report a case of a 15-years-old boy with presumably congenital tracheoesophageal (H type) fistula. He has a history of recurrent bronchitis, bronchopneumonia and cough after liquid swallowing. Soon after an episode of blood stained sputum, a tracheal orifice in the pars membranacea that opened into the esophagus was found by fiberoptic bronchoscopy study. Chest and abdominal X-rays showed esophageal air and abdominal distention, respectively. The esophagram showed the passage of contrast agent to the tracheobronchial tree and no additional concurrent lesions. Cervical and thoracic magnetic resonance images revealed the location, morphology and anatomical relation to the neighbouring structures of the tracheoesophageal fistula, which was repaired surgically by left lateral cervicotomy and direct section and suture. The posterior wall of the trachea was reinforced with a muscle flap, with good results.