Surgical management of chylothorax.

BACKGROUND: Chylothorax remains an uncommon but challenging clinical problem. Thoracic duct ligation is the treatment of choice for postsurgical patients. However, the optimal treatment for traumatic patients is unclear. We wanted to examine the outcomes of patients with high output or recurrent chylothorax who were treated by surgical means. METHODS: From December 1992 to April 2008, 29 patients underwent surgical procedures for high output (> 1 L/day) (16) or recurrent chylothorax (13). We analyzed these patients to determine the surgical approach, perioperative complications, and outcomes of the treatment approach. RESULTS: Of the 29 patients, 12 patients developed chylothorax following esophagectomy, in 5 patients it resulted from lymphoproliferative disorders, in 2 patients following ascending aneurysm repair, in 2 after trauma, in 3 following lung resection, and in 1 patient respectively from coronary artery bypass grafting (CABG), thymectomy for thymoma, vasculitis, and metastatic lung cancer, while 1 patient had no clear etiology. The median age of patients was 61 (range 20-79) years. 22 patients initially underwent thoracic duct ligation, 6 had talc pleurodesis, and one underwent bilateral pleuroperitoneal shunt placement. Approaches for thoracic duct ligation included: right thoracotomy (16), left thoracotomy (3), VATS (2), and right thoracotomy together with laparotomy (1). There were no intraoperative complications or deaths within 30 days or during postoperative hospitalization. The success rate after initial thoracic duct ligation was 95 % (21/22). One patient needed re-exploration after ligation with resolution of chylothorax after the second operation. The success rate after pleurodesis was 83 % (5/6). One patient after pleurodesis needed subsequent thoracic duct ligation for resolution of bilateral chylothoraces. All patients in this series had resolution of chylothorax. CONCLUSIONS: Thoracic duct ligation is the treatment of choice for high output or recurrent chylothorax with a 96 % success rate. Surgical pleurodesis is effective in some cases and may be an option for marginal patients.

Preoperative chemotherapy for esophageal cancer with paclitaxel and carboplatin: results of a phase II trial.

OBJECTIVE: Paclitaxel has one of the highest response rates when used as a single agent in patients with esophageal cancer. The combination of paclitaxel and carboplatin has been shown to be a well-tolerated and safe regimen in non-small cell lung cancer. The objective of this study was to determine the efficacy of preoperative paclitaxel and carboplatin in patients with carcinoma of the esophagus. PATIENTS AND METHODS: A phase II trial was initiated in January 1999 and concluded in January 2001. All patients had potentially resectable disease (including clinical T4 lesions). Patients with stage I disease and those with visceral metastases were excluded. All underwent preoperative computed tomography scanning and endosonography for staging. Paclitaxel (200 mg/m(2)) and carboplatin (area under the curve = 6) were given on days 1 and 22. Esophagectomy was carried out on weeks 6 to 8. RESULTS: Twenty-six (11 epidermoid, 15 adenocarcinoma) patients completed the trial. Median age was 61.5 and 85% were men. Preoperative staging showed: stage IIA, 6 patients; stage IIB, 1 patient; and stage III, 19 patients. All patients completed their preoperative chemotherapy. There was no unexpected chemotherapy-related toxicity. A major clinical response was achieved in 16 patients (61%: 19% complete, 42% partial). Resectability was 77% (20/26). A complete pathologic response was seen in 11% of all patients and in 25% of those with epidermoid cancer. Hospital mortality and morbidity were 4 and 27%, respectively. Overall 3-year survival was 48% (64% for resected patients, median not reached). All 6 unresectable patients died within 6 months of exploration. CONCLUSION: Paclitaxel-carboplatin combination is a safe and well-tolerated regimen for esophageal cancer with clinical response rates comparable to historical controls. This regimen may be especially suitable for patients with epidermoid cancer, who had a 25% pathological complete response in this report.

Celecoxib, a selective cyclo-oxygenase-2 inhibitor, enhances the response to preoperative paclitaxel and carboplatin in early-stage non-small-cell lung cancer.

PURPOSE: Preclinical studies suggest that treatment with a selective cyclo-oxygenase-2 (COX-2) inhibitor may augment the antitumor effects of chemotherapy. In this study, patients with non-small-cell lung cancer (NSCLC) were preoperatively treated with celecoxib in combination with chemotherapy. End points were toxicity, response rates, and measurement of intratumoral levels of prostaglandin E2 (PGE2). METHODS: In this phase II trial, 29 patients with stages IB to IIIA NSCLC were treated with two preoperative cycles of paclitaxel and carboplatin, as well as daily celecoxib, followed by surgical resection. Levels of PGE2 in the primary tumors and adjacent normal lung tissue were compared in 17 study patients versus 13 controls, who received preoperative paclitaxel/carboplatin without celecoxib. RESULTS: All patients completed preoperative chemotherapy, and 26 completed preoperative celecoxib. The overall clinical response rate was 65% (48% with partial response; 17% with complete response). Grade 3 or 4 neutropenia was observed in 18 patients (62%). Twenty-eight patients were explored and underwent complete resection of their tumors. There were no complete pathologic responses, but seven patients (24%) had minimal residual microscopic disease. The addition of celecoxib to a regimen of paclitaxel and carboplatin abrogated the marked increase in levels of PGE2 detected in primary tumors after treatment with paclitaxel and carboplatin alone. CONCLUSION: In comparison with historically reported response rates, these data suggest that the addition of a selective COX-2 inhibitor may enhance the response to preoperative paclitaxel and carboplatin in patients with NSCLC. Moreover, treatment with celecoxib 400 mg twice daily was sufficient to normalize the increase in PGE2 levels found in NSCLC patients after treatment with paclitaxel and carboplatin. Confirmatory trials are planned.

Surgery for thymoma.

Although thymoma is an uncommon tumor, it represents the most frequently encountered tumor of the anterior mediastinum. These tumors represent an interesting and even peculiar group of lesions by virtue of their association with paraneoplastic disorders, their relatively indolent course, and their predisposition for local recurrence. The initial treatment of choice for patients with thymoma that do not present with unresectable local or diffuse metastatic disease is complete surgical resection. The goals of surgery are complete excision of the lesion with total thymectomy and complete exploration to rule out the presence of noncontiguous disease that may be resectable. Often, complete resection may require the resection of surrounding involved structures including pericardium, pleura, lung, and even major vascular structures. Some authors have suggested VATS or VATS-assisted techniques for small thymomas. Capsular invasion, however, often can be subtle, and the completeness of resection is of prime importance in countless studies. With recurrences appearing up to 5 and even 10 years postoperatively, time will tell if these minimally invasive techniques are comparable with current standard approaches. Multiple studies have failed to determine conclusively the role of induction chemotherapy and adjuvant radiation. Prospective multi-institutional trials are required to elucidate further the role of such therapies in these rare tumors. In the interim, the authors continue to recommend postoperative radiation for all patients undergoing resection with the exception of stage I patients. Some promising reports on response to chemotherapy have led them to develop an induction chemotherapy protocol for patients with clinically advanced disease.

Isolated lung perfusion with FUDR in the rat: pharmacokinetics and survival.

BACKGROUND: Although surgical resection remains the mainstay of treatment for metastatic pulmonary colorectal cancer, 5-year survival approaches only 30% to 40%. We have developed a model of isolated left lung perfusion (ILP) with FUDR (2'-deoxy-5-fluorouridine) for the treatment of pulmonary colorectal metastases. FUDR ILP toxicity and pharmacokinetics were evaluated and compared with continuous intravenous infusion in the rat. METHODS: Toxicity was first evaluated in F344 rats (n = 17) after left ILP (20-minute perfusion at 0.5 mL/min) with 21 mg/mL (n = 11), 28 mg/mL (n = 2), 35 mg/mL (n = 2), and 70 mg/mL (n = 2) of FUDR. Animals were followed up and weights recorded for 14 days postoperatively before a right pneumonectomy was performed to evaluate the effect of FUDR perfusion on left lung function. In the second study, 32 rats (n = 8/group) underwent: systemic FUDR (intravenous), or ILP with 7, 14, and 21 mg/mL respectively (ILP 7, ILP 14, and ILP 21 groups). Left lungs and serum were analyzed for FUDR and 5-fluorouracil by high-performance liquid chromatography. RESULTS: Rats perfused with doses of FUDR greater than 21 mg/mL died perioperatively. All animals perfused at 21 mg/mL survived until day 14, and 8/11 survived a right pneumonectomy. Rats that survived ILP resumed normal weight gain and grooming habits within 1 week. Pharmacokinetic evaluation demonstrated that ILP at 21 mg/mL maximally elevated total lung FUDR and 5-fluorouracil levels (508.5 +/- 96.4 micrograms/g lung) in comparison with the ILP 14, ILP 7, and intravenous groups (299.1 +/- 44.8, 116.0 +/- 21.1, and 7.5 +/- 4.1 micrograms/g lung, respectively) (p < 0.05). Serum FUDR levels were 10.5 +/- 6.8, 1.3 +/- 0.5, 2.31 +/- 1.1, and 1.2 +/- 0.4 microgram/g lung (p = not significant) for intravenous, ILP 7, ILP 14, and ILP 21 groups, respectively. CONCLUSIONS: Isolated left lung perfusion with FUDR is well tolerated to a maximum dose of 21 mg/mL and results in significantly higher FUDR and 5-fluorouracil lung levels with low serum levels compared with intravenous treatment. These higher pulmonary levels may offer advantages in the treatment of pulmonary colorectal metastases.

Depletion of high energy phosphate compouds in the tumor-bearing state and reversal after tumor resection.

BACKGROUND: Cancer cachexia is a syndrome manifested by a variety of metabolic abnormalities that include depletion of host energy stores. We studied liver and skeletal muscle high energy phosphate compounds, inorganic phosphorus (Pi), and the energy charge in tumor-bearing (TB), pair fed non-tumor-bearing (NTB), and tumor-bearing resected (RES) rats. METHODS: F344 rats were randomized into TB (n = 13), NTB (n = 13), and RES (n = 5) groups. On day 0, the flanks of the TB and RES animals were injected with 1 x 10(7)n methylcholanthrene (MCA)-induced sarcoma cells. On day 19, TB and NTB rat liver and skeletal muscle were analyzed for adenine nucleotides, phosphocreatine, and Pi, and RES animals underwent tumor resection followed by tissue analysis 10 days later. RESULTS: Although the liver adenylate energy charge was maintained, the level of liver adenosine monophosphate was significantly increased and the liver adenosine diphosphate level was decreased in the TB animals (3.55 +/- 0.6, 3.70 +/- 0.3 mumoles/gm dry weight, p < 0.05, p = 0.05, respectively) when compared with the NTB animals (3.06 +/- 0.4, 4.00 +/- 0.5 mumoles/gm dry weight, respectively). Muscle adenosine diphosphate levels were significantly decreased in the TB animals (1.57 +/- 0.7 mumoles/gm dry weight) as compared with NTB animals (2.23 +/- 0.7 mumoles/gm dry weight, p < 0.05). In addition, muscle adenosine triphosphate, phosphocreatine, and phosphocreatine/adenosine triphosphate ratios were significantly decreased in TB animals (19.94 +/- 4.5, 81.51 +/- 12.8, and 4.20 +/- 0.8 mumoles/gm dry weight, respectively) as compared with NTB animals (24.44 +/- 1.9, 116.72 +/- 7.5, and 4.81 +/- 0.4 mumoles/gm dry weight, respectively, p < 0.05) and RES animals (24.08 +/- 3.3, 124.10 +/- 12.2, and 5.19 +/- 0.5 mumoles/gm dry weight, respectively, p < 0.05). CONCLUSIONS: These alterations in high energy phosphate compounds in liver and skeletal muscle indicate that although the energy charge is maintained, energy depletion occurs early in the tumor-bearing state. These changes are tumor specific, not related to anorexia, and revert to non-tumor-bearing levels after tumor resection.

Pulmonary artery perfusion of doxorubicin with blood flow occlusion: pharmacokinetics and treatment in a metastatic sarcoma model.

BACKGROUND: We compared pharmacokinetics, toxicity, and treatment efficacy of pulmonary artery perfusion of low-dose doxorubicin with blood flow occlusion to intravenous doxorubicin injection in a metastatic sarcoma model in the rat. METHODS: Animals received left pulmonary artery perfusion with 0.1, 0.2, or 0.5 mg/kg doxorubicin at a rate of 0.1 mL/min for 1 minute with 20 minutes of blood flow occlusion. Doxorubicin levels of the lung, heart, and serum were assayed. Body weights after treatment were recorded and right pneumonectomy was performed. The results were compared with those in rats that received 5 mg/kg doxorubicin by intravenous injection or the saline group. Pulmonary sarcoma metastases were treated with 0.5 mg/kg doxorubicin through lung perfusion or intravenously, or with saline solution. RESULTS: Doxorubicin levels in the lung, heart, and serum were 112.1 +/- 9.2 micrograms/g, 1.7 +/- 0.2 microgram/g, and 0.3 +/- 0.1 microgram/mL in the group with 0.5 mg/kg doxorubicin perfusion, versus 24.8 +/- 1.9 microgram/g, 10.1 +/- 1.3 microgram/g, and 0.7 +/- 0.2 microgram/mL in the intravenous group (p < 0.05). Animals had normal growth patterns and survived after right pneumonectomy in the perfused group, whereas the intravenous group failed to thrive. No tumors were found or a significant reduction in nodules was noted in the lungs treated with perfusion as compared with untreated right lungs or the intravenous and saline groups. CONCLUSION: This chemotherapy model has important pharmacokinetic advantages and causes an increased treatment response for pulmonary metastatic sarcoma with minimal systemic and local toxicity as compared with systemic doxorubicin administration.

Thymoma: a multivariate analysis of factors predicting survival.

BACKGROUND: Despite complete surgical excision, malignant thymomas often recur with resultant death. We reviewed our series to determine which factors independently predict survival after surgical resection. METHODS: A retrospective analysis of patients operated on for thymoma between 1949 and 1993 at Memorial Sloan-Kettering Cancer Center was performed. Clinical data were collected from chart review. Only patients with a pathology report confirming the diagnosis of thymoma were included in this analysis. Kaplan-Meier survival curves were generated and comparisons of survival analyzed by log rank test. Multivariate analysis was performed by the Cox proportional hazard model. RESULTS: One hundred eighteen patients with thymoma underwent operation. There were 86 complete resections (73%), 18 partial resections (15%), and 14 biopsies (12%). By Masaoka staging, 25 patients were stage I (21%), 41 stage II (35%), 43 stage III (36%), and 9 stage IVa (8%). Overall survival was 77% at 5 years and 55% at 10 years. Tumor recurred in 25 (29%) of 86 completely resected thymomas. Stage of disease (p = 0.03) was the only independent prognostic factor affecting recurrence. By multivariate analysis, stage (p = 0.003), tumor size (p = 0.0001), histology (p = 0.004), and extent of surgical resection (p = 0.0006) were independent predictors of long-term survival. CONCLUSIONS: Patients with stage I disease require no further therapy after complete surgical resection. Neoadjuvant therapy should be considered for patients with large tumors and invasive disease.

Buthionine sulfoximine pretreatment potentiates the effect of isolated lung perfusion with doxorubicin.

BACKGROUND: Although surgical resection remains the mainstay of treatment for metastatic pulmonary sarcoma, 5-year survival approaches only 25%. Chemotherapy has been limited by tumor resistance and systemic toxicity. We assessed the efficacy of L-buthionine-SR-sulfoximine, an inhibitor of glutathione synthesis, as a sensitizer for isolated lung perfusion. METHODS: In experiment 1, sarcoma-bearing rats (n = 20) received either buthionine sulfoximine via intraperitoneal injection or Hespan. After the last injection, tumor glutathione levels were measured. In experiment 2, rats (n = 60) were injected with sarcoma intravenously. On day 6, animals were pretreated with either buthionine sulfoximine or Hespan intraperitoneally. On day 7, rats underwent isolated lung perfusion (Hespan or doxorubicin) or intravenous therapy (Hespan or doxorubicin). On day 14, tumor nodules were counted. RESULTS: Buthionine sulfoximine effectively depleted tumor glutathione. Animals treated with intravenous therapy had no response to therapy, whereas those animals treated with doxorubicin isolated lung perfusion alone had a limited response. Buthionine-sulfoximine pretreatment in combination with doxorubicin isolated lung perfusion led to a 13-fold reduction in tumor nodules and 5 complete responses. CONCLUSIONS: Buthionine-sulfoximine pretreatment in combination with doxorubicin isolated lung perfusion is superior to intravenous doxorubicin and doxorubicin isolated lung perfusion alone for the treatment of metastatic pulmonary sarcoma.

Revised technique of isolated lung perfusion in the rat.

Isolated lung perfusion in the rat is a useful research tool. Pulmonary arteriotomy and venotomy repair is required for animal survival. Rat pulmonary vessels are fragile, thin, and small in caliber, making their repair the focal technical point. This technique has been improved. The arteriotomy now is closed with a single suture and the venotomy no longer requires repair. The lung is returned to its original anatomic position then compressed to stop bleeding. These improvements have improved animal morbidity and mortality markedly while reducing operating time.

Perioperative growth hormone improves wound healing and immunologic function in rats receiving adriamycin.

Administration of perioperative growth hormone may reverse alterations in wound healing and immunologic function in animals receiving chemotherapy. F344 rats were randomized into three groups: Control (n = 12), Chemo (n = 13), and Chemo + GH (n = 12). Human growth hormone (GH) (3 mg/kg sc bid) was begun on Day 0 and continued for 2 weeks. On Day 7, all animals underwent a standardized midline laparotomy, gastrotomy, and placement of a subcutaneous wound sponge. In addition, a single dose of adriamycin (5 mg/kg i.v.) was administered to those animals receiving chemotherapy. On Day 12, right hindlimb footpads were challenged with 50 micrograms of dinitrochlorobenzene. On Day 14, bursting strengths of the laparotomy and gastrotomy were measured. The wound sponge and gastric anastomosis were analyzed for hydroxyproline (OH-Pro) content. Animal spleens were weighed and splenocytes harvested for NK cell activity. Delayed type hypersensitivity (DTH) is reported as percentage of hind-limb foot pad swelling (%FPS). Data are expressed as means +/- SD and comparisons by ANOVA. The laparotomy bursting strength (mm Hg) in the Chemo + GH group (81 +/- 14) was significantly higher than that in the Chemo group (66 +/- 15, P < 0.05). The anastomotic tissue OH-Pro levels (mumole/g dry tissue) in the Chemo + GH group (107.9 +/- 15.2) were significantly higher than those in the Chemo group (62.9 +/- 8.5, P < 0.001). GH increased splenic weights (mg) over those of Chemo (0.50 +/- 0.13 vs 0.37 +/- 0.05, P < 0.05). NK cell activity (% killing) was significantly elevated in the Chemo+GH group compared to that in Chemo.(ABSTRACT TRUNCATED AT 250 WORDS)

Isolated lung perfusion with FUDR is an effective treatment for colorectal adenocarcinoma lung metastases in rats.

Currently, the only treatment capable of significantly prolonging survival in patients with isolated pulmonary metastases from colorectal adenocarcinoma is complete resection. Systemic chemotherapy has been shown to provide little benefit. We evaluated the efficacy of highdose, organ-specific 2'-deoxy-5-fluorouridine (FUDR) using a model of isolated single-lung perfusion (ILP) in the rat. On day 0, 28 BDIX rats were inoculated intravenously with 10(6) viable Sp-5 colorectal adenocarcinoma cells. On day 10 after-tumor inoculation, animals were randomized into five treatment groups. Group I received a continuous intravenous infusion of FUDR (1 mg.kg-1.d-1) for 7 days administered by an osmotic minipump. Group II underwent isolated left lung perfusion with a buffered Hespan solution, groups III to V underwent ILP with 3.5, 7, and 14 mg of FUDR per milliliter of the buffered Hespan solution, respectively. Animals undergoing ILP were anesthetized with pentobarbital, intubated, and ventilated, and then underwent left thoracotomy with cannulation of the pulmonary artery; the pulmonary artery and vein were clamped proximally. Groups II to V were perfused for 20 minutes at a rate of 1 mL/min, followed by a 5-minute washout with FUDR-free buffered Hespan solution. On day 26 after tumor inoculation, the animals in all groups were sacrificed and their lungs were stained and counted. Animals that underwent ILP with 14 mg of FUDR per milliliter of the buffered Hespan solution showed a significant decrease in the number of tumor nodules on the treated side versus the number on the untreated side (455.2 +/- 87.3 versus 11 +/- 6.4; p < 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Marrow space imaging in Hodgkin's disease. MRI prior to biopsy for improved accuracy.

PURPOSE: Accurate staging of Hodgkin's disease is essential for choosing appropriate therapy. PATIENTS AND METHODS: A case of a 13-year-old boy with a history of Hodgkin's disease and negative iliac crest biopsies is presented. RESULTS: MRI-guided biopsy led to the accurate diagnosis of bone marrow involvement and a change in patient management. CONCLUSIONS: Magnetic resonance imaging has the potential to detect focal marrow involvement and therefore direct biopsy site.

Computed tomography of relapsing polychondritis.

The CT findings of a patient with relapsing polychondritis involving the larynx, tracheobronchial tree, and nasal cartilage are described. In the proper clinical setting, a characteristic constellation of findings when noted on CT can aid in differentiating this rare inflammatory disease from other causes of airway compromise. CT is the most useful imaging modality, because cartilage and soft tissue components are well visualized. If diagnosed early, appropriate treatment may prevent life-threatening airway obstruction.

Case report: extramedullary plasmacytoma of the larynx.

A case of extramedullary plasmacytoma of the larynx is presented. The case is unique for the extramedullary plasmacytoma's marked extension into the mediastinum. The computed tomography (CT) features are described.

Sulphur acquisition by Neisseria meningitidis.

Group B Neisseria meningitidis (SD1C) was grown on defined medium supplemented with each of a variety of sulphur compounds as the sole source of sulphur. The organism grew on sulphate, sulphite, bisulphite, thiosulphate, dithionite, hydrosulphide, thiocyanate, L-cysteine, L-cystine, reduced glutathione, methionine, mercaptosuccinate, and lanthionine, but not on dithionate unless previously sulphur starved. Good growth was seen on concentrations of sulphate or thiosulphate as low as 10 microM. When pregrown on and subsequently starved for sulphate, the meningococcus showed enhanced transport capacity for this ion. Optimal conditions for assessing sulphur transport by active sulphur-limited cells were determined. The maximal sulphate uptake velocity was 9.3 nmol sulphate X mg protein-1 X min-1, and the apparent Km was 1.4 microM, far below human nasopharyngeal or serum sulphate levels.